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Thermal Imaging History Form

June 20, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative
Positive
Right Results
Negative
Positive

Chest, Heart & Lung 

Have you been diagnosed with Heart Disease?*
No
Yes
Have you been diagnosed with Lung Disease? *
No
Yes
Have you been diagnosed with Upper Spine Disorders?*
No
Yes
Do you suffer with upper back pain? *
No
Yes
Do you suffer with chest pain?*
No
Yes
Have you ever been diagnosed with Scoliosis?*
No
Yes
Have you ever had surgery to your heart?*
No
Yes
Have you ever had surgery to your lungs?*
No
Yes
Have you ever had surgery to your mid to upper back?*
No
Yes
Do you have asthma or shortness of breath?*
No
Yes
Do you currently smoke?*
No
Yes
Have you smoked in the past five years? *
No
Yes
Do you suffer with shoulder pain? *
No
Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *
No
Yes
Do you suffer pain in the stomach? *
No
Yes
Do you suffer Pain below left or right breast? *
No
Yes
Do you suffer pain in the abdomen? *
No
Yes
Do you suffer pain in the lower back? *
No
Yes
Do you suffer pain in the lower pelvic region?*
No
Yes
Have you had surgery or disease in the
Stomach
Spleen(upper left)
Liver(upper right)
Kidneys
Intestines
Abdomen
Lower Back
Pelvic Region
Have you consumed alcohol in the past 24 hrs? *
No
Yes
Have you ever had surgery in the:
Stomach
Liver (upper right)
Intestines
Lower Back
Spleen (upper left)
Kidneys
Abdomen
Pelvic Region

Legs & Feet 

Do you suffer pain in the leg?*
No
Yes
Do you suffer pain in the sciatica? *
No
Yes
Do you suffer pain in the Buttocks/Hip? *
No
Yes
Do you suffer pain in the knees?*
No
Yes
Do you suffer pain in the ankles? *
No
Yes
Do you suffer pain in the feet? *
No
Yes
Have you had surgery to the Legs? *
No
Yes
Have you had surgery to the Sciatica? *
No
Yes
Have you had surgery to the Buttocks/Hips *
No
Yes
Have you had surgery to the Knees? *
No
Yes
Have you had surgery to the ankles? *
No
Yes
Have you had surgery to the feet? *
No
Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands 

Do you suffer from pain in the shoulders? *
No
Yes
Do you suffer from pain in the elbow? *
No
Yes
Do you suffer from pain in the arm? *
No
Yes
Do you suffer from pain in the hands? *
No
Yes
Have you had surgery to your shoulders? *
No
Yes
Have you had surgery to your arms? *
No
Yes
Have you had surgery to your hands? *
No
Yes
Have you had surgery to your elbows? *
No
Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement. 

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck 

Do you suffer from headaches?*
No
Yes
Do you have know allergies? *
No
Yes
Do you have TMJ or does your jaw click? *
No
Yes
Do you currently have a cold? *
No
Yes
Are you being treated for a Thyroid disorder? Yes No *
No
Yes
Do you have neck pain? *
No
Yes
Do you have upper back pain? *
No
Yes
Do you have a known history of coritid artery disease? *
No
Yes
Do you have a family history of stroke?*
No
Yes
Do you currently suffer with sinus problems?*
No
Yes
Do you have history of dental problems? *
No
Yes
Dental Problems:
Root Canals
Gum Disease
Non-Replaced Extractions
Mercury Fillings
Implants
Dentures
Have you had a dental cleaning in the past 7 days? *
No
Yes
Have you been diagnosed with elevated cholesterol?*
No
Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness
Left
Right
Lumps
Left
Right
Change in breast size
Left
Right
Areas of skin changes, thickening or dimpling
Right
Left
Excretion or changes of the nipple
Left
Right
Are any of the above symptoms cycle related? *
No
Yes
Are you still having your periods? *
No
Yes
Have you had a surgical hysterectomy?*
No
Yes
If yes to hysterectomy
Partial
Complete

What is Date of hysterectomy?
Reason for hysterectomy:
excess bleeding
endometriosis
fibroid cycts
cancer
Other

If "Other", please specify
Has anyone in your family been treated for breast cancer? *
No
Yes
Family member diagnosed with breast cancer:
Mother
Grandmother
Sister
Daughter

What was the age of family member diagnosed?
Result of family members cancer?
Survived
Terminal
Have you ever been diagnosed with breast cancer? *
No
Yes
Cancer Type:
local
Lymph node involvement
Mestastatic
Left Breast
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Treatment
Surgery
Chemo
Radiation
None
If Surgery
Mastectomy
Lumpectomy
Have you ever been diagnosed with any other breast disease/? *
No
Yes
If yes,
Cysts/Fibrocystic
Fibro Adenoma
Mastitis/inflammatory breast disease
Have you ever had any cosmetic breast surgery or implants?*
No
Yes
Breast Surgery:
Silicone
Saline
Experience
Problems
No Problems
Have you ever had any biopsies or other surgeries to your breast?*
No
Yes
Left Breast:
Inner
Outer
Nipple
Right Breast
Inner
Outer
Nipple
Results
Negative
Positive
Calcifications
Have you ever taken contraceptive pills
Currently
Less than 5
More than 5
Have you had pharmaceutical hormone replacement therapy? HRT
Currently
Less than 5 years
More than 5 years
Do you have an annual physical examination by a doctor? *
No
Yes
Do you perform a montly self breast exam?*
No
Yes
Have you ever smoked? *
No
Yes
Have you ever been diagnosed with diabetes?*
No
Yes

Total Mammograms:

Date of last mammogram.
Were you recalled?*
No
Yes

Age at first mammogram:

Number of full term pregnancies:
Have you ever had breast ultrasound?*
No
Yes
Left Results
Negative