• Breast Health Screening Form

  • Please check your status
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred location of scan:*
  • Are you a patient of any providers at the above locations?*
  • Were you referred by another health care practitioner?*

  • The charge for Breast Infrared Thermal Imaging is $260 ($140 for current Carolina Center patients seen within one year).  Payment is due in advance to reserve your appointment and is refundable up to 14 days prior to the scheduled appointment less a $50 processing fee (refund amount $210).  No refund will be provided for cancellations made with less than 14 days prior notification. 

    If cancellation is made with less than 14 days prior notification, a 50% cancellation fee credit will be given to reschedule that appointment within the next 7 days to be seen within the next 14 days or the next available appointment, whichever is first ($105 credit).

  • CURRENT MEDICATIONS AND SUPPLEMENTS:

  • Have you recently had any of these breast symptoms?
    Rows
  • When was your last breast exam?
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.

  • Image field 138

  • Reporting for Left Breast

    Input N/A if not applicable.

  • Reporting for Right Breast

    Input N/A if not applicable.
  • Are any of the above symptoms cycle related?
  • Are you still having your periods?*
  • Have you had a surgical hysterectomy?*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What type?*
  • Reason for hysterectomy?*
  • Has anyone in your family ever been treated for breast cancer?*
  • Please supply answers for each family member below.
    Rows
  • Have you ever been diagnosed with breast cancer?*
  • Diagnosis Month and Year*
  • Cancer Type:*
  • Left Breast:
  • Right Breast:
  • Treatment:*
  • Please answer all that apply.
    Rows
  • Any palpable mass now?*
  • Any discharge, inversion or change in nipples?*
  • Have you ever been diagnosed with any other breast disease?*
  • Please choose all that apply.
  • Have you had any cosmetic breast surgery or implants?*
  • Month and Year*
  • Type of implant*
  • Have you ever had any biopsies or any other surgeries to your breasts*
  • Month and Year*
  • Which side(s)? Check all that apply.*
  • Left Breast: Please check all that apply.*
  • Right Breast: Please check all that apply.*
  • Have you ever taken contraceptive pills for more than one year?*
  • Duration: Please check all that apply.*
  • Have you had pharmaceutical hormone replacement therapy (HRT)?*
  • Duration: Please check all that apply.*
  • Do you have an annual physical examination by a doctor?*
  • Do you perform a monthly breast self-exam?*
  • Have you ever smoked?*
  • Have you ever been diagnosed with diabetes?*
  • Have you had a mammogram?*
  • Month and Year of most recent mammogram*
  • Results: Please check all that apply.*
  • Have you had breast ultrasound?*
  • Month and Year of most recent ultrasound*
  • Which side(s) was scanned? Check all that apply.*
  • Result for right side only.*
  • Result for left side only.*
  • Have you had breast MRI?*
  • Month and Year of most recent breast MRI*
  • Which side(s) was scanned? Check all that apply.*
  • Result for right side only.*
  • Result for left side only.*
  • Have you ever undergone Infrared Thermal Breast Imaging?*
  • Month and Year of most recent Infared Thermal Breast Imaging*
  • Which side(s) was scanned? Check all that apply.*
  • Result for right side only.*
  • Result for left side only.*

  • 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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: