Breast Thermography Confidential Questionnaire

Breast Thermography Confidential Questionnaire
Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Address
City
Zip
Email
Phone
Format: (000) 000-0000.
Doctor
All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting ther- mologist and any other practitioner that you specify.

Please Mark Yes Or No As It Applies To You:
Do you have any close relative who has had breast cancer ?
Have you ever been diagnosed with breast cancer ?
Have you ever been diagnosed with any other breast disease (fibrocystic)?
Have you had any biopsies or surgeries to your breasts?
Have you had any breast cosmetic surgery or implants?
Have you had a mammogram in the past 12 months?
Have you had a mammogram in the past 5 years?
Have you had abnormal results from any breast testing?
Have you ever taken a contraceptive pill for more than a year?
Have you suffered with uterine or ovarian cancer?
Have you had pharmaceutical hormone replacement therapy?
Do you have an annual physical examination by a doctor?
Do you perform a monthly breast self exam?
Did your period start before the age of 12?
Did your period finish after the age of 50?
Had a vaccination in last 4 weeks? Indicate which arm
How many mammograms have you had in total?
What was your age when you had your first mammogram?
How many births have you had?
Your age at the birth of your first child
Do you smoke?
Breast Thermography Confidential Questionnaire

Have you recently had any of these breast symptoms?
Mark Right Breast or Left Breast as it applies
Pain (Right Breast)
Pain (Left Breast)
Tenderness (Right Breast)
Tenderness (Left Breast)
Lumps (Right Breast)
Lumps (Left Breast)
Change in breast size (Right Breast)
Change in breast size (Left Breast)
Areas of skin thickening or dimpling (Right Breast)
Areas of skin thickening or dimpling (Left Breast)
Secretions of the nipple (Right Breast)
Secretions of the nipple (Left Breast)
PATIENT DISCLOSURE:

I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report.
By signing below, I certify that I have read and understand the statements above and consent to the examination.
Signed
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Breast Thermography Confidential Questionnaire

Please Mark Yes Or No As It Applies To You:

Breast Thermography Confidential Questionnaire

Mark Right Breast or Left Breast as it applies