Breast Thermography Confidential Questionnaire

Breast Thermography Confidential Questionnaire
Name*
Birthdate*

MonthDayYear
Address
City
Zip
Email
Phone
Format: (000) 000-0000.
Doctor
All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting ther- mologist and any other practitioner that you specify.

Please Mark Yes Or No As It Applies To You:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
How many mammograms have you had in total?
What was your age when you had your first mammogram?
How many births have you had?
Your age at the birth of your first child
Did your period start before the age of 12?
Or finish after the age of 50?
YesNeverNot in the last 12 monthsNot in the last 5 years
LeftRightNo
Breast Thermography Confidential Questionnaire

Have you recently had any of these breast symptoms?
Mark Right Breast or Left Breast as it applies
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
PATIENT DISCLOSURE:

I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis 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, disease, 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 statements above and consent to the examination.
Signed*
Date

MonthDayYear
Date
Should be Empty:

Breast Thermography Confidential Questionnaire

Please Mark Yes Or No As It Applies To You:

Breast Thermography Confidential Questionnaire

Mark Right Breast or Left Breast as it applies