Breast Thermography Confidential Questionnaire Contact Page

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Breast Thermography Confidential Questionnaire Contact PageSammy2023-09-12T20:08:02-05:00

Breast Thermography Confidential Questionnaire

Name *

Date of Birth *

Address *

City *

Zip Code *

Email *

Phone Number *

Primary Doctor *

Have you been diagnosed with Breast Cancer? *

If yes, when? *

Cancer Type *

Metastic? *

Local *

Lymph Node Involvement *

Where (left breast)

upper/outer

upper/inner

lower/outer

lower/inner

nipple

None

Where (right breast)

upper/outer

upper/inner

lower/outer

lower/inner

nipple

None

Treatment:

None

Surgery

Chemotherapy

Radiation

If breast radiaton was treatment- date of last treatment? *

Left or Right Breast? *

Any other treatment? *

Any breast reconstruction after mastectomy? *

If yes, what type? *

Left or Right Breast? *

Have you been diagnosed with any other breast disease (fibrocystic, cystic, mastitis, dense breast tissue, abscess, or other)? *

Have you had any biopsies, lumpectomies, or surgeries to your breasts? *

If yes, Date? *

Was the result Positive or Negative? *

Left Breast or Right Breast? *

Where at?

Upper/Outer

Upper/Inner

Lower/Outer

Lower/Inner

Nipple

None

Have you had any breast cosmetic surgery?

Implants

Reduction

Lift

None

Do you have any close relatives who has had breast cancer? *

Have you had a Mammogram in the past 12 months? *

What was the date? *

Was it Normal, Abnormal, Suspicious, or inconclusive?

Normal

Abnormal

Suspicious

Inconclusive

None

Right or Left?

Select option

Right

Left

None

Have you had a Mammogram in the past 5 years *

What was the date? *

Was it Normal, Abnormal, Suspicious, or inconclusive?

Normal

Abnormal

Suspicious

Inconclusive

None

Right or Left?

Select option

Right

Left

None

Was follow up biopsy recommended after your recent mammogram, ultrasound, or Mri? *

Have you had any abnormal results from any breast testing? *

If yes, briefly explain: *

Do you perform a monthly breast exam? *

Do you have an annual physical examination by a doctor? *

What was your age when you had your first mammogram? *

How many mammograms have you had in total? *

Are you currently nursing? *

Are you currently pregnant? *

Have you had pharmaceutical hormone replacement therapy? *

Have you used bioidentical hormone? *

If yes, what kind?

Gel/cream

Oral

Pellet

None

Have you been diagnosed with ovarian, cervical or uterine Cancer? *

If yes, when and what kind? *

Have you had any of the following?

Hysterectomy

Oophorectomy (ovaries)

Total/ Radical hysterectomy (uterus+Ovaries+Tubes)

None

Have you ever had cancer of the womb? *

If yes date? *

Have you ever taken a contraceptive pill/patch for more than 1 year? *

Did you start your period before the age of 12? *

Did your periods finish after the age of 50? *

Are you still having a monthly period? *

How many births had you had? *

What was your age when your first child was born? *

Do you smoke? *

Have you Recently/Currently experienced any of these symptoms

Pain in left breast

Pain in right breast

Tenderness in left breast

Tenderness in right breast

Lumps in left breast

Lumps in right breast

Change of size in left breast

Change of size in right breast

Areas of skin thickening/dimpling in left breast

Areas of skin thickening/dimpling in right breast

Secretions of the nipples in left breast

Secretions of the nipples in right breast

None

If experiencing nipple discharge- is it

Bloody

Milky

Clear

None

If nipple retraction- How many years? *

Was it recently? *

Left or Right Breast or both?

Left

Right

Both

None

Patient Disclosure *

I understand that the Report generated from my images is intended for my use by trained health care providers to assist in evaluation, diagnosis & 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 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 the consent to the examination. *

Today's Date *

Thank you for your message. It has been sent.

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