Intake Form

Thermography

Participant Information

Reminders

  • Can NOT have any sunburns
  • Do NOT work out 3 hours before your thermography
  • No lotion, deodorant, and makeup
  • For breast imaging, you can’t be currently breastfeeding (must be 3 months out from last
    breastfeeding session)

Symptoms & History

Are you referred by your physician?
Are you self-referred?
Do you see a dentist yearly?

Female Patients Only

Are you currently breastfeeding?

Breast Questionnaire

Any close relative who has had breast cancer?
Ever been diagnosed with breast cancer?
Ever been diagnosed with any other breast disease?
Ever had any biopsies or surgeries on your breasts?
Ever had any breast cosmetic surgeries or implants?
Had a mammogram in the past 12 months?
Had a mammogram in the past 5 years?
Any abnormal results from any breast testing?
Ever taken a contraceptive pill for more than 1 year?
Ever suffered from uterine or ovarian cancer?
Ever had hormone replacement therapy?
Have an annual physical breast examination by a doctor?
Do you perform a monthly breast self-exam?
Did the patient's periods start before the age of 12?
Did the patient's periods end after the age of 50?
Had vaccination in the past 4 weeks? Indicate which arm.
Does the patient smoke now or has ever smoked in the past?

Has the Patient recently had any of these breast symptoms:

Pains?
Change in breast size?
Secretions of the nipple?
Tenderness?
Areas of skin thickening or dimpling?

Breast Biopsies or Surgeries

Upper Outer
Lower Outer
Nipple
Upper Inner
Lower Inner