Breast Thermography

Please complete this form for your file for an initial Breast Thermography appointment.

Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date of Birth / MM / DD YYYY
Email
Best Daytime Phone Number - (###) - ### ####
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Please List Medications that you are currently taking (one medication on each line.
If you would like to have a copy of this exam sent to another physician please list the name of the physician and their complete address.
Any close relative who had had breast cancer? * Yes No
Ever been diagnosed with breast Cancer? * Yes No
Ever been diagnosed with any other breast disease? * Yes No
Ever had any biopsies or surgeries to breasts? * Yes No
Ever have any breast cosmetic surgery or implants? * Yes No
Had A mammogram in the past 12 months? * Yes No
Had A mammogram in the past 5 years? * Yes No
Any abnormal results from any breast testing? * Yes No
Ever taken a contraceptive pill for more than 1 year? * Yes No
Ever suffered with cancer of the womb? * Yes No
Ever had hormone replacement therapy * Yes No
Have an annual physical by a doctor? * Yes no
Perform a monthly breast self exam? * Yes No
Total number of mammograms? *
Age of first mammogram *
Number of children given birth to? *
Age at birth of first child? *
Age at which periods started? *
Or finished after the age of? *
Smoker? * Yes Never Not in the last 12 months Not in the last 5 years
Recently had the breast symptom of: PAIN? * Left Breast Right Breast Both Breast None
Recently had the breast symptom of: Tenderness? * Left Breast Right Breast Both Breast None
Recently had the breast symptom of: Lumps? * Left Breast Right Breast Both Breast None
Recently had the breast symptom of: Change in breast size? * Left Breast Right Breast Both Breast None
Recently had the breast symptom of: Areas of skin thickening or dimpling? * Left Breast Right Breast Both Breast None
Recently had the breast symptom of: Secretions of the niples? * Left Breast Right Breast Both Breast None
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Diagnosed with Breast Cancer Cancer Type? * Metastatic Local Lymph node involvement None
When Diagnosed (Leave blank if not applicable) / MM / DD YYYY
Where in the LEFT BREAST? * UO UI LO LI Nipple None
Where in the RIGHT BREAST? * UO UI LO LI Nipple None
Treatment * Surgery Chemo Radiation Other None
Diagnosed with other breast disease Type? * Fibrocystic Cystic Mastitis Abscess Other (refer history) None
Breast Biopsies or Surgery: Left Breast: * UO UI LO LI Nipple None
Breast Biopsies or Surgery: Right Breast: * UO UI LO LI Nipple None
Type the letters you see in the image below.

Breast Thermography

Breast Thermography

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