Breast Thermography Confidential Questionnaire

Where (left breast)
Where (right breast)
Treatment:
Where at?
Have you had any breast cosmetic surgery?
Was it Normal, Abnormal, Suspicious, or inconclusive?
Right or Left?
Was it Normal, Abnormal, Suspicious, or inconclusive?
Right or Left?
If yes, what kind?
Have you had any of the following?
Have you Recently/Currently experienced any of these symptoms
If experiencing nipple discharge- is it
Left or Right Breast or both?