Breast Health Screening Form

Breast Health Screening

This is a confidential questionnaire. Please fill it out to the best of your ability and click the submit button below.
Full Name*
Date of Birth*

MonthDayYear
Age*
Address*
Best phone number to reach you*
Type of phone*
Alternate phone number
Type of phone
Email*
Please tell us how you heard about Carolina Thermascan*
Preferred location of scan:*

Carolina Center - RaleighCarolina Center - WilmingtonFamily Functional Medicine - Greensboro
Are you a patient of any providers at the above locations?*

YesNo
If yes, we will provide a copy of your report to that practitioner. *
Were you referred by another health care practitioner?*

YesNo
If yes, we will send a copy of your scan and report to that practitioner. *
CURRENT MEDICATIONS AND SUPPLEMENTS:
Medications: input N/A if not applicable*
Supplements: input N/A if not applicable*
Allergies: input N/A if not applicable*
Is there a specific reason/concern for this breast exam? input N/A if not applicable*

Have you recently had any of these breast symptoms?

	Left	Right	Both Left and Right
Pain/Tenderness
Lumps
Change in breast size
Areas of skin changes thickening or dimpling
Excretions or changes of the nipple

When was your last breast exam?

MonthDayYear
Who performed your last breast exam?
REPORTING CURRENT BREAST SYMPTOMS
PROCEDURE

1. Start by identifying any of the symptoms you my be experiencing below.
- Mass
- Thickening
- Discharge
- Nipple Change
- Skin Change
- Area of Pain
- Burning
- Tender
- Dull Ache
- Sharp Pain
- Other
2. Using the image of the clock below determine the corresponding region of the breast that is experiencing the symptom.

For example: the bottom, center region of the breast would be represented by the 6 on the clock. Likewise, the upper, right region of the breast would be represented by the 2 on the clock.
Reporting for Left Breast

Input N/A if not applicable.
Example: If you were experiencing "Burning" in the bottom, center of your breast, you would report this as "6 Burning." If you were experiencing a "Mass" in the upper, right region of the breast you would report "2 Mass."*
Reporting for Right Breast

Input N/A if not applicable.
Example: If you were experiencing "Burning" in the bottom, center of your breast, you would report this as "6 Burning." If you were experiencing a "Mass" in the upper, right region of the breast you would report "2 Mass."*
Are any of the above symptoms cycle related?

YesNo
Are you still having your periods?*

YesNo
Have you had a surgical hysterectomy?*

YesNo
Date*

MonthDayYear
What type?*

CompletePartial
Reason for hysterectomy?*

Excess BleedingEndometriosisFibroid cystsCancerOther
Has anyone in your family ever been treated for breast cancer?*

YesNo

Have you ever been diagnosed with breast cancer?*

YesNo
Diagnosis Month and Year*
Location*
Outcome*
Cancer Type:*

LocalMetastaticLymph node involvement
Left Breast:

InnerOuterNipple
Right Breast:

InnerOuterNipple
Treatment:*

SurgeryChemoSurgeryNone

Any palpable mass now?*

NoYes, left breastYes, right breast
Any discharge, inversion or change in nipples?*

NoYes, left breastYes, right breast
Have you ever been diagnosed with any other breast disease?*

YesNo
Please choose all that apply.

Cysts/fibrocysticFibro AdenomaMastitis/inflammatory breast disease
Have you had any cosmetic breast surgery or implants?*

YesNo
Month and Year*
Type of implant*

SilioneSaline
Please explain if you had any issues with the implant(s). Input N/A if not applicable*
Have you ever had any biopsies or any other surgeries to your breasts*

YesNo
Month and Year*
Which side(s)? Check all that apply.*

RightLeft
Left Breast: Please check all that apply.*

InnerOuterNippleNegativePositiveCalcifications
Right Breast: Please check all that apply.*

InnerOuterNippleNegativePositiveCalcifications
Have you ever taken contraceptive pills for more than one year?*

YesNo
Duration: Please check all that apply.*

CurrentlyMore than 5 yearsLess than 5 years
Have you had pharmaceutical hormone replacement therapy (HRT)?*

YesNo
Duration: Please check all that apply.*

CurrentlyMore than 5 yearsLess than 5 years
Do you have an annual physical examination by a doctor?*

YesNo
Do you perform a monthly breast self-exam?*

YesNo
Have you ever smoked?*

YesNo
Have you ever been diagnosed with diabetes?*

YesNo
Have you had a mammogram?*

YesNo
Age at first mammogram*
Month and Year of most recent mammogram*
Results: Please check all that apply.*

NormalAbnormalSuspiciousCalled back for a repeat?
Have you had breast ultrasound?*

YesNo
Month and Year of most recent ultrasound*
Which side(s) was scanned? Check all that apply.*

RightLeft
Result for right side only.*

PostiveNegative
Result for left side only.*

PostiveNegative
Have you had breast MRI?*

YesNo
Month and Year of most recent breast MRI*
Which side(s) was scanned? Check all that apply.*

RightLeft
Result for right side only.*

PostiveNegative
Result for left side only.*

PostiveNegative
Have you ever undergone Infrared Thermal Breast Imaging?*

YesNo
Month and Year of most recent Infared Thermal Breast Imaging*
Which side(s) was scanned? Check all that apply.*

RightLeft
Result for right side only.*

PostiveNegative
Result for left side only.*

PostiveNegative
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.

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.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Should be Empty:

	Yes/No	Age at Diagnosis	Still Living?
Mother
Sister
Daughter
Maternal Grandmother
Maternal Aunt
Maternal Cousin
Paternal Grandmother
Paternal Aunt
Paternal Cousin

	Surgery	Year of surgery/treatment	Side
Lumpectomy
Mastectomy
Breast Reconstruction
Radiation to Breast
Chemotherapy
Breast Augmentation

Breast Health Screening

CURRENT MEDICATIONS AND SUPPLEMENTS:

REPORTING CURRENT BREAST SYMPTOMS

Reporting for Left Breast

Reporting for Right Breast