Female Thermography Paperwork

Female Thermography Paperwork
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.
How did you hear about us?*

Current ClientGoogleRadio - KXOJTVFacebookInstagramTiktokEmailPsychology TodayAnother Business or PhysicianOther
Did a doctor's office refer you?*

YesNo
Which doctor's office?
Clinical Concerns:*
Current Symptoms: *
Current Treatment:*
Current Medication: *
Family History:*
Dental History:*
Please list all surgeries since birth and approximate date of surgery.*
General Health History: *
Skin Lesions or Physical Abnormalities *
All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting thermologist and any other practitioner that you specify.

Please answer "Yes" or "No" to the following
Do you have any close relative who has had breast cancer?*

YesNo
Relationship to relative?
Ever been diagnosed with breast cancer?*

YesNo
When were you diagnosed?
Cancer Type:

MetastaticLocalLymph node involvement
Where (Left Breast):

UO (Upper Outer)UI (Upper Inner)LO (Lower Outer)LI (Lower Inner)NippleN/A
Where (Right Breast):

UO (Upper Outer)UI (Upper Inner)LO (Lower Outer)LI (Lower Inner)NippleN/A
Ever been diagnosed with any other breast disease?*

YesNo
What type?

FibrocysticCysticMastitisDense breast tissueAbscessOther
Have you had any biopsies or non cosmetic surgeries to your breast?*

YesNo
When?
Where (Left Breast):

UO (Upper Outer)UI (Upper Inner)LO (Lower Outer)LI (Lower Inner)NippleN/A
Where (Right Breast):

UO (Upper Outer)UI (Upper Inner)LO (Lower Outer)LI (Lower Inner)NippleN/A
Have you had any breast cosmetic surgery or implants?*

YesNo
When?
Have dense breast tissue?*

YesNo
Have you had a mammogram in the past 12 months?*

YesNo
When was the approx. date?
Was it:

NormalAbnormalSuspiciousInconclusive
Had more than 30 mammograms in your life?*

YesNo
Have you had a mammogram in the past 5 years?*

YesNo
How many mammograms have you had?*
Age at first mammogram? Put 0 for none.*
Was it:

NormalAbnormalSuspiciousInconclusive
Have you had abnormal result from breast testing?*

YesNo
Have you ever taken an oral contraceptive for more than 4 years?*

YesNo
Have you ever taken an oral contraceptive for more than 1 year?*

YesNo
Have you been diagnosed with ovarian, uterine, or cervical cancer?*

YesNo
Have you had hormone replacement therapy?*

YesNo
Do you have an annual physical examination by a doctor?*

YesNo
Do you perform a monthly breast self exam?*

YesNo
Did your periods start before the age of 12?*

YesNo
Did your periods finish after the the age of 50?*

YesNo
How many children have you given birth to?*
What was your age when you gave birth to your first child?
Have you ever smoked for more than 5 years?*

YesNo
Do you currently smoke?*

YesNo
Is your menstrual cycle irregular?*

YesNoI don't have a menstrual cycle.
Experience cramping during menstrual cycle?*

YesNoI don't have a menstrual cycle.
Do you experience heavy bleeding during your menstrual cycle?*

YesNoI don't have a menstrual cycle.
Experience breast pain or tenderness?*

YesNo
Have any breast lumps?*

YesNo
Do you have low libido?*

YesNo
Do you have hot flashes?*

YesNo
Have you ever been diagnosed with endometriosis?*

YesNo
Have you ever been diagnosed with PCOS (poly cystic ovarian syndrome)?*

YesNo
Have you ever been treated for infertility?*

YesNo
Do you have any swelling in the neck or trouble swallowing?*

YesNo
Have you been diagnosed with any thyroid disorder?*

YesNo
Do you regularly experience fatigue?*

YesNo
Have you experienced recent hair loss?*

YesNo
Have you had a:

HysterectomyOophorectomy(overies)Total/radical hysterectomy (Uterus+Ovaries+Tubes)
Have you had the COVID vaccine in the past 4 weeks? Which arm?

Right armLeft armNo
Have you recently/currently experienced any of these breast symptoms?

PainTendernessLumpsChange in breast sizeAreas of skin thickening or dimplingSecretions of the nipple
Pain

Right BreastLeft BreastBoth
Tenderness

Right BreastLeft BreastBoth
Lumps

Right BreastLeft BreastBoth
Change in breast size

Right BreastLeft BreastBoth
Areas of skin thickening or dimpling

Right BreastLeft BreastBoth
Secretions of the nipple

Right BreastLeft BreastBoth
If you have been diagnosed with breast cancer, please answer the following questions.
Treatment:

SurgeryChemoRadiationOtherNone
Date of last treatment?
Which breast?
Any breast reconstruction after mastectomy?

YesNo
What type? (ex: trans flap, implant)
Which breast?

RightLeft
Have you done Thermography before?*

YesNo
Patient Disclosure

I understand that the report generated from my images is intended for use by trained healthcare providers to assist in evaluations, 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 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 statements above and the content of the examination.

I authorize Soaak Clinics and their specially trained associate technicians of this facility to perform Thermography.
Signature

Clear
Should be Empty: