Clone of Chesapeake Retired Firefighter Patient Medical History Form

Chesapeake Breast Health Questionnaire
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient E-Mail*
example@example.com
Date of Birth*

MonthDayYear
Age*
Less than 1 year1-5 years5-10 years10-15 years15-20 yearsGreater than 20 years
I hereby release the screening physician, Hampton Roads Ultrasound and all other healthcare volunteers from all responsibility in connection with this screening exam. I understand that I will only be screened for risk factors or symptoms of breast disease and cancer and that this screening does not constitute a complete medical exam or diagnosis, and that I do not have a physician-patient relationship with the screening physician by virtue of this screening exam. I further understand that I will receive a copy of my screening results. I may receive a follow-up phone call from a licensed medical provider. It is solely my responsibility to seek any appropriate follow-up medical treatment as indicated by my screening results. No one may use my examination results for any purpose, other than statistical study as long as no identifying information is published. I consent to ultrasound testing performed by Hampton Roads Ultrasound. I have read and understand this form and understand the information presented.

To view our full HIPPA agreement click here.
YesNo
Primary Care Physician

First NameLast Name
Breast Screening Description

Breast ultrasound screening is a non-invasive procedure that uses sound waves to create detailed images of the breast. It is often recommended when there are concerns about breast abnormalities or dense breast tissue, which can make it difficult to see certain changes on mammograms. The procedure involves a handheld device called a transducer, which sends sound waves into the breast and captures the echoes as they bounce off the tissue. These echoes are then converted into images by a computer, allowing healthcare providers to assess the breast's internal structures. Breast ultrasound is particularly useful for detecting small cancers that may be hidden in normal breast tissue and is not part of routine mammogram screening.
Acknowledgement - Receipt of Notice of HIPPA Agreement and Privacy Practices and Exam Descriptions.*

Clear
Unresolved breast lumpBreast painNipple dischargeBreast abnormality found on examChange in breast skin dimpling, puckering, redness, etc.Significant breast trauma
YesNo
If yes, please specify the date and type of imaging completed.
Date of last clinical breast exam/physical:
YesNo
If yes, please specify the dates of use:
Beginning date of last period:
Age of first period:
How many times have you been pregnant?
How many living children do you have?
YesNo
YesNo
If yes, please list starting and end dates:
Allergies*
AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaThyroid ProblemsTuberculosisNeurological DisordersBleeding DisordersLung DiseaseEmphysemaExcessive alcohol useCancerFamily history of cancerNoneOther
Surgical History*
Leg cramps with walking/pain with walkingTenderness in abdomenDifficulty speakingBack painDizzinessHeadachesNumbness or weakness on one side of bodyLoss of balance or coordinationSudden loss of visionPelvic painAbnormal vaginal bleedingAdnexal (right or left pelvic pain)Abnormal hot or cold sensitivityChest painPalpitationsShortness of breath at restAbnormal shortness of breath on exertionEasy bruisingHallucinationsConfusionNose bleedsMouth soresDiarrheaNoneOther
Appointment*
I certify that all the information provided is accurate to the best of my ability and I consent to the cardiovascular and/or early detection cancer screening examinations.
Signature*

Clear
Should be Empty:

Chesapeake Breast Health Questionnaire