Breast Health Form
Breasts4LIFE
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Scan (Date of Appointment)
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
F
M
Age
*
Scan Type
*
Initial Scan
Follow Up Scan
Describe any current breast concerns such as lumps, pain, skin changes, radiographic findings or other concerns:
*
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Mark the area of any current concerns on the diagrams below -Only If Applicable
Mobile device or touch screen users, use your finger to circle or mark the areas of concern or if using a mouse click and hold to circle or mark the areas of concern on each diagram.
Right Side
Left Side
Front
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Last Physical Breast Examination by a Health Care Provider:
*
None
My Last Exam was on (date below)
Date of Last Physical Breast Exam
-
Month
-
Day
Year
Date
Last Physical Breast Results
Normal
Other
Last Mammogram
*
None
My Last Mammogram was on (date below)
Date of Last Mammogram
-
Month
-
Day
Year
Date
Mammogram Type
Right
Left
Both
Last Mammogram Results
Normal
Other
Last Breast Ultrasound
*
None
My Last Ultrasound was on (date below)
Date of Last Breast Ultrasound
-
Month
-
Day
Year
Date
Breast Ultrasound Type
Right
Left
Both
Last Breast Ultrasound Results
Normal
Other
Last Breast MRI
*
None
My Last MRI was on (date below)
Date of Last Breast MRI
-
Month
-
Day
Year
Date
Breast MRI Type
Right
Left
Both
Last Breast MRI Results
Normal
Other
Breast Biopsy
*
None
My Last Biopsy was on (date below)
Date of Last Breast Biopsy
-
Month
-
Day
Year
Date
Breast Biopsy Type
Right
Left
Both
Last Breast Biopsy Results
Benign
Pre-Cancer
Cancer
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Section 1: Breast Cancer
Breast Cancer
*
None
Left
Right
Both
Date of Diagnosis
-
Month
-
Day
Year
Date
Cancer Treatment
Lumpectomy Date
-
Month
-
Day
Year
Date
Mastectomy Date
-
Month
-
Day
Year
Date
Reconstruction Date
-
Month
-
Day
Year
Date
Radiation Treatment - Date of Last Treatment
-
Month
-
Day
Year
Date
Other treatment
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Section 2: General
Benign Breast Surgery:
*
None
Lumpectomy
Implants
Reduction
Lumpectomy
Right
Left
Lumpectomy Date
-
Month
-
Day
Year
Date
Implants Date
-
Month
-
Day
Year
Date
Reduction Date
-
Month
-
Day
Year
Date
Fibrocystic breasts, Breast Cysts, or General Breast Lumpiness
*
Yes
No
Other benign breast conditions:
*
None
Yes
Currently Breast feeding:
*
No
Yes
Last Breast Nursed:
Right
Left
Breast Most Favored:
Right
Left
Pregnant:
*
Yes
No
Current cycle day (# of days since 1st day of period):
Menopause
*
No
Yes
Age of last menses:
Currently experiencing symptoms of:
*
Menopause
Perimenopause
Neither
Both ovaries removed:
*
Yes - Check only if both have been removed
No
Family history of breast cancer:
*
Yes
No
Past injury to the breasts:
*
None
Right
Left
Both
Date of Injury:
-
Month
-
Day
Year
Date
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Section 3: Selected Hormones and Factors Effecting Them
Current Hormones:
*
None
Estrogen
Progesterone
Testosterone
Thyroid hormone
Current supplements to support the following:
*
None
Breast Health
Hormonal Balance
Inflammation
Thyroid Function
Are you currently engaged in any lifestyle activities or diet designed to:
*
None
Promote breast health
Reduce inflammation
Promote hormonal balance
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INFORMED CONSENT FOR TESTING PROCEDURE
Thermal Breast Imaging (otherwise known as breast thermography) detects and visualizes the thermal emissions (temperature) occurring at the surface of the breasts. The purpose of the examination is to detect signs of inflammation or unusual blood vessel activity that could suggest risk for current and/or future risk for cancer.
Initials
*
I understand that Thermal Breast Imaging is used only as an adjunct to primary screening examinations such as physical breast examination, mammography, breast ultrasound and breast MRI and does not replace any other breast examination or screening. I also understand that thermal imaging does not and cannot directly detect or be used to diagnose breast cancer. Nor can it rule out the presence of breast cancer since some cancers do not produce sufficient temperature changes at the surface of the breasts to be seen with thermography. Therefore, breast cancer may still be present despite thermal imaging revealing a low risk. For that reason, thermal imaging does not replace any other breast examination. All breast concerns including but not limited to skin changes, nipple discharge, lumps or other abnormalities, clinical findings and radiographic findings require evaluation by a medical doctor regardless of the thermal imaging results. Use of thermography as a stand-alone detection examination is not recommended as it can result in the failure of an existing cancer to be detected. I
Initials
*
I confirm that I have followed the written pre-examination protocols for breast imaging provided to me before the examination. I understand that if I did not receive or follow these protocols, the accuracy of my examination may be compromised.
Initials
*
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By signing below, I hereby acknowledge that (1) I have read and understood each of the above paragraphs; (2) I have had an opportunity to ask any questions I may have had; (3) any questions I asked were answered to my satisfaction; (4) I have received sufficient information with respect to thermal imaging to make an informed decision to undergo the procedure; (5) I understand no guarantee or warranty is being made that all risk for current and/or future cancer will be detected; and (6) I hereby authorize and consent to thermal imaging
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
STATEMENT OF INDEPENDENT OPERATIONS:
I understand and agree that Robert L. Kane, D.C., D.A.B.C.T., dba Kane Thermal Imaging Interpretive Services (collectively referred to as "Kane Interpretive Services") is a California based company that contracts with the provider of your imaging services solely for the purpose of interpreting and reporting thermal imaging scans. Your provider is not an employee, officer, director, partner, representative or agent of Kane Interpretive Services. Nor is Kane Interpretive Services an employee, officer, director, partner, representative or agent of your provider. Kane Interpretive Services is a wholly separate business entity from your provider and does not oversee or supervise your provider's thermography operations. Kane Interpretive Services is not involved in the design, manufacture, marketing, sale, rental, distribution, installation, inspection, repair or modification of any machinery or products used by your provider. Rather, Kane Interpretive Services is an independent contractor hired by your provider solely to interpret thermal imaging data and to report the results. Kane Thermal Interpretive Services does not control, nor have the right to control, your provider's business, including its equipment, operations, advertising and/or representations. Kane Interpretive Services makes no promises, warranties or representations, express or implied, as to your provider's services. In addition, Kane Interpretive Services owes no duty of care to me in connection with provider's services, including no duty to screen provider, no duty to protect or warn me of any actions or inactions of provider and no duty to investigate, communicate or mitigate any risks, known or unknown, relating to provider's services. I assume all duty of reasonable care to select, screen and monitor provider's services for my own safety and protection. By signing this Statement of Independent Operations, I understand and agree with the foregoing and further agree that Dr. Robert L. Kane, D.C., D.A.B.C.T., dba Kane Thermal Imaging Interpretive Services is only responsible to me for the content of the thermal imaging report and its accompanying reporting guide.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
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