FORM #1: Whole Body Health Screening Questionnaire

  • Whole Body Health Screening Questionnaire

  • Please check your status
  • Date of Birth*
     - -
  • 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 Whole Body Infrared Thermal Imaging is $1115 which includes a 30 minute consultation with Dr. John Pittman, Certified Thermologist.  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 $1065).  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 $750 cancellation fee credit will be given to reschedule that appointment within 7 days to be seen within the next 14 days or the next available appointment, whichever is first.  

  • CURRENT MEDICATIONS AND SUPPLEMENTS:

  • Rows
  • When was 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.

  • 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?*
  • Since your last thermal image, have you had a surgical hysterectomy?*
  • Date*
     - -
  • What type?*
  • Reason for hysterectomy?*
  • Has anyone in your family ever been treated for breast cancer since your last thermal image?*
  • Rows
  • Have you been diagnosed with new breast cancer since your last thermal image?*
  • Cancer Type:*
  • Left Breast:
  • Right Breast:
  • Treatment:*
  • Rows
  • Any palpable mass now?*
  • Any discharge, inversion or change in nipples?*
  • Have you ever been diagnosed with any other breast disease since your last thermal image?*
  • Please choose all that apply.
  • Have you had any cosmetic breast surgery or implants since your last thermal image?*
  • Type of implant*
  • Have you ever had any biopsies or any other surgeries to your breasts since your last thermal image*
  • 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 had a mammogram?*
  • Results: Please check all that apply.*
  • Have you had breast 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?*
  • 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?*
  • Which side(s) was scanned? Check all that apply.*
  • Result for right side only.*
  • Result for left side only.*
  • Have you ever smoked?*
  • Have you ever been diagnosed with diabetes?*
  • Have you recently had any of these symptoms?
  • Have you had a cold within the last 7 days
  • Have you had a dental cleaning within the last 7 days
  • Do you have acid reflux or other digestive problems
  • Do you have pain in the:
  • Have you had surgery or disease in the

  • 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*
     - -
  • Should be Empty: