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    Breast Questionnaire

    Uploaded by

    albimar239512
    Breast cancer & thermography

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Breast Questionnaire

    Uploaded by

    albimar239512
    8 views2 pages
    Breast cancer & thermography

    Original Title

    breast-questionnaire

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Breast cancer & thermography

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    8 views2 pages

    Breast Questionnaire

    Uploaded by

    albimar239512
    Breast cancer & thermography

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Confidential Questionnaire

    Breast
    Name Birth Date Today’s Date
    Address City State Zip
    Phone Number Home Cellular Work
    E-Mail Address
    Referring Physician
    Is there a specific reason or concern for this exam?

    Yes No

    1. Have you recently had any of these breast symptoms? (mark only if “yes”) __ __
    LT RT
    Pain/Tenderness ___ ___
    Lumps ___ ___
    Change in breast size ___ ___
    Areas of skin changes thickening or dimpling ___ ___
    Excretions or changes of the nipple ___ ___
    2. Are any of the above symptoms cycle related? __ __
    3. Are you still having your periods? __ __
    4. Have you had a surgical hysterectomy? ___ __
    If yes, date Complete __ Partial ___
    Reason for hysterectomy?
    ○ Excess bleeding ○ Endometriosis ○ Fibroid cysts ○ Cancer ○ Other
    5. Has anyone in your family ever been treated for breast cancer? __ __
    If yes, note age and survival ○ Mother ○ Grandmother ○ Sister ○ Daughter
    Age diagnosed ________ Result of Treatment_________________________________
    6. Have you ever been diagnosed with breast cancer? __ __
    If yes, date: Month ______ Year _________
    Cancer type ○ Local ○ Metastatic ○ Lymph node involvement
    Left breast ○ Inner ○ Outer ○ Nipple
    Right breast ○ Inner ○ Outer ○ Nipple
    Treatment ○ Surgery ○ Chemo ○ Radiation ○ None

    7. Have you ever been diagnosed with any other breast disease? __ __
    If yes, ○ Cysts/fibrocystic ○ Fibro Adenoma ○ Mastitis/inflammatory breast disease
    8. Have you had any cosmetic breast surgery or implants? __ __
    If yes, date ○ Silicone ○ Saline
    Experience: ○ Problems ○ No problems
    -1-
    Yes No

    9. Have you ever had any biopsies or any other surgeries to your breasts __ __
    If yes, date
    Left breast ○ Inner ○ Outer ○ Nipple
    Right breast ○ Inner ○ Outer ○ Nipple
    Results ○ Negative ○ Positive ○ Calcifications
    10. Have you ever taken contraceptive pills for more than one year? __ __
    If yes, ○ Currently ○ Less than 5 years ○ More than 5 years
    11. Have you had pharmaceutical hormone replacement therapy (HRT)? __ __
    If yes, ○ Currently ○ Less than 5 years ○ More than 5 years
    12. Do you have an annual physical examination by a doctor? __ __
    13. Do you perform a monthly breast self exam? __ __
    14. Have you ever smoked? __ __
    15. Have you ever been diagnosed with diabetes? __ __
    16. Total mammograms
    17. Date of last mammogram ______ Were you re-called? __ __
    18. Your age at your first mammogram?
    19. Number of full term pregnancies? _______
    20. Have you had breast ultrasound? __ __
    If yes…Date:____/____ Left ___ Right___ Results: Negative___ Positive ___

    21. Have you had breast MRI? __ __


    If yes…Date:____/____ Left ___ Right___ Results: Negative___ Positive ___

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

    Procedure: You will be imaged with a state of the art infrared imaging camera in comfortable and controlled surroundings.
    Your thermal imaging baseline reports will provide information about current and future conditions only and does not
    diagnose breast disease. Thermal imaging should be correlated with other medical investigative methods to better direct
    definitive testing for diagnosis and treatment. It does not replace any other breast examination.

    Client Disclosure: I understand that the report generated from my images is intended for use by a trained health care
    provider to assist in evaluation and treatment. I further understand that the report is not intended to be used by myself for self-
    evaluation or self-diagnosis. I understand that the report will not tell me whether, I have any illness, diseases, or other
    conditions, 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 statement above and consent to the examination.

    Client Signature Today’s Date


    -2-

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