Name:

Birthdate:

Address:

City:

State:

Zip:

Phone (H):

(C):

(W):

Todays Date:

Has anyone in your family ever been treated for breast cancer?  Yes     No

If Yes  Mother Grandmother Sister Daughter

Have you had abnormal results from any breast testing? Yes     No

If yes:  Date

Have you ever been diagnosed with breast cancer? Yes     No

If yes:  Date

Cancer type: Local Metastatic Lymph node involvement

Left breast: Inner     Outer     Nipple

Right breast: Inner     Outer     Nipple

Treatment: Surgery      Chemo     Radiation      None

Have you ever been diagnosed with any other breast disease? Yes     No

If yes:  Cysts/fibrocystic Mastitis/Inflammatory breast disease Fibro adenoma

Have you had any cosmetic breast surgery or implants? Yes     No

If Yes:  Date    

Silicone     Saline

Experience:   Problems      No Problems

Have you ever had any biopsies or any other surgeries to you breasts? Yes     No

If Yes:  Date    

Left breast: Inner     Outer     Nipple

Right breast: Inner     Outer     Nipple

Results:   Negative      Positive      Calcifications

Patient Name:

Have you ever taken contraceptive pills for more than 1 year?   Yes     No

If Yes  Currently Less than 5 years More than 5 years

Have you had pharmaceutical hormone replacement therapy?   Yes     No

If Yes  Currently Less than 5 years More than 5 years

Do you have an annual physical examination by a doctor?    Yes     No

Do you perform a monthly breast self exam?   Yes     No

Have you ever smoked?    Yes     No

Have you ever been diagnosed with diabetes?   Yes     No

How many mammograms have you had in total?

Your age at your first mammogram?

Date of your last mammogram                      

Were you re-called?   

How many children have you given birth to?

Your age at birth of your first child

Age when you started your period?

How do you rate your stress level:  No stress Mild stress Very stressed

Are you still having your periods?   Yes     No

Are any of the above symptoms cycle related?   Yes     No

Date of last period:

Patient Name:

Have you had a surgical hysterectomy?   Yes     No

If Yes:  Date    

 Full       Partial  Excess bleeding Endometriosis Fibroid cysts Cancer Other

Procedure: We will image you with a high-resolution computerized thermal imaging camera in a controlled environment. When reading these images, we look for certain temperature findings in the breasts which may suggest elevated risk for disease. Thermal imaging provides information about current and future risk only and does not diagnose breast conditions. Thermal imaging findings should be correlated with diagnostic examinations before a final diagnosis and treatment decision is made. It does not replace any other breast examination.

Patient 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 individuals for self-evaluation or self-diagnosis. I understand that the report will not tell me whether, I have any illness, diseases, or other condition, 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

Signature:       Today’s Date: