• Women's Wellness Bundle Paperwork

    Women's Wellness Bundle Paperwork

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Did a doctor's office refer you?*

  • 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?*
  • Ever been diagnosed with breast cancer?*
  • Cancer Type:
  • Where (Left Breast):
  • Where (Right Breast):
  • Ever been diagnosed with any other breast disease?*
  • What type?
  • Have you had any biopsies or non cosmetic surgeries to your breast?*
  • Where (Left Breast):
  • Where (Right Breast):
  • Have you had any breast cosmetic surgery or implants?*
  • Have dense breast tissue?*
  • Have you had a mammogram in the past 12 months?*
  • Was it:
  • Had more than 30 mammograms in your life?*
  • Have you had a mammogram in the past 5 years?*
  • Was it:
  • Have you had abnormal result from breast testing?*
  • Have you ever taken an oral contraceptive for more than 4 years?*
  • Have you ever taken an oral contraceptive for more than 1 year?*
  • Have you been diagnosed with ovarian, uterine, or cervical cancer?*
  • Have you had hormone replacement therapy?*
  • Do you have an annual physical examination by a doctor?*
  • Do you perform a monthly breast self exam?*
  • Did your periods start before the age of 12?*
  • Did your periods finish after the the age of 50?*
  • Have you ever smoked for more than 5 years?*
  • Do you currently smoke?*
  • Is your menstrual cycle irregular?*
  • Experience cramping during menstrual cycle?*
  • Do you experience heavy bleeding during your menstrual cycle?*
  • Experience breast pain or tenderness?*
  • Have any breast lumps?*
  • Do you have low libido?*
  • Do you have hot flashes?*
  • Have you ever been diagnosed with endometriosis?*
  • Have you ever been diagnosed with PCOS (poly cystic ovarian syndrome)?*
  • Have you ever been treated for infertility?*
  • Do you have any swelling in the neck or trouble swallowing?*
  • Have you been diagnosed with any thyroid disorder?*
  • Do you regularly experience fatigue?*
  • Have you experienced recent hair loss?*
  • Have you had a:
  • Have you had the COVID vaccine in the past 4 weeks? Which arm?
  • Have you recently/currently experienced any of these breast symptoms?
  • Pain
  • Tenderness
  • Lumps
  • Change in breast size
  • Areas of skin thickening or dimpling
  • Secretions of the nipple

  • If you have been diagnosed with breast cancer, please answer the following questions.

  • Treatment:
  • Any breast reconstruction after mastectomy?
  • Which breast?
  • Have you done Thermography before?*

  • 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.

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