Contact Information

Enter your name *

Phone *

Enter your email address *

Address *

Enter your home address

Birthday *

Select the month of your birthdate

*

Type the day of your birthdate

*

Type the year of your birthdate

How did you hear about Thermal Imaging Center? *

Name of person who referred you?

Specific Reason

Is there a specific reason for this exam?

Head & Neck

Do you suffer with headaches? *

Yes

No

How many per month?

Do you have known allergies? *

Yes

No

What type?

Food

Environmental

Do you have TMJ or does your jaw click? *

Yes

No

Do you currently have a cold? *

Yes

No

Are you being treated for a thyroid disorder? *

Yes

No

Type?

Do you have neck pain? *

Yes

No

Do you suffer with upper back pain? *

Yes

No

Do you have a known history of carotid artery disease? *

Yes

No

Do you have a family history of stroke? *

Yes

No

Do you currently suffer with sinus problems? *

Yes

No

Do you have history of dental problems? *

Yes

No

Type?

Root canal

Gum disease

Implant

Have you had dental cleaning in the past 7 days? *

Yes

No

Have you ever been diagnosed with high cholesterol? *

Yes

No

Breasts

Have you recently had any of these breast symptoms?

Pain/Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes thickening or dimpling

Left

Right

Excretions or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

No

Are you still having your periods? *

Yes

No

Date of the first day of your last cycle?

Have you had a surgical hysterectomy? *

Yes

No

When?

Extent

Complete

Partial

Reason(s) for hysterectomy?

Excess bleeding

Endometriosis

Fibroid cysts

Cancer

Other

Other Reason

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

Yes

No

Who?

Grandmother

Mother

Sister

Daughter

Age diagnosed?

Result of treatment?

Have you ever been diagnosed with breast cancer? *

Yes

No

When?

Cancer type:

Local

Metastatic

Lymph node involvement

Left breast:

Inner

Outer

Nipple

Right breast:

Inner

Outer

Nipple

Treatment(s):

Have you ever been diagnosed with any other breast disease? *

Yes

No

Type(s)?

Cysts/fibrocystic

Fibroadenoma

Mastitis/inflammatory breast disease

Have you had any cosmetic breast surgery or implants? *

Yes

No

When?

Type?

Silicone

Saline

How did it go?

Had problems

No problems

Have you ever had any biopsies or any other surgeries to your breasts? *

Yes

No

When?

Left breast:

Inner

Outer

Nipple

Right breast:

Inner

Outer

Nipple

Results:

Negative

Positive

Calcifications

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

Yes

No

Have you had pharmaceutical hormone replacement therapy (HRT)? *

Yes

No

When?

Currently

Less than 5 years ago

More than 5 years ago

Do you have an annual physical examination by a doctor? *

Yes

No

Do you perform a monthly breast self exam? *

Yes

No

Have you ever smoked? *

Yes

No

Have you ever been diagnosed with diabetes? *

Yes

No

Total mammograms:

Date of last mammogram:

Were you re-called? *

Yes

No

Your age at your first mammogram?

Number of full term pregnancies? *

Have you had breast ultrasound? *

Yes

No

When?

Which breast?

Left

Right

Result?

Negative

Positive

Have you had breast MRI? *

Yes

No

When?

Which breast?

Left

Right

Result?

Negative

Positive

Chest, Heart & Lungs

Have you been diagnosed with:

Heart disease? *

Yes

No

Lung disease? *

Yes

No

Upper spine disorders? *

Yes

No

Do you suffer with chest pain? *

Yes

No

Have you ever had surgery to your:

Heart? *

Yes

No

Lungs? *

Yes

No

Mid to upper back? *

Yes

No

Do you have asthma or shortness of breath? *

Yes

No

Do you currently smoke? *

Yes

No

Have you smoked in the past 5 years? *

Yes

No

Have you consumed alcohol in the past 24 hours? *

Yes

No

Abdomen & Lower Back

Do you suffer with acid reflux or other digestive problems? *

Yes

No

Do you suffer pain in the:

Stomach? *

Yes

No

Below right breast? *

Yes

No

Below left breast? *

Yes

No

Abdomen? *

Yes

No

Lower back? *

Yes

No

Pelvic region? *

Yes

No

Have you had surgery or disease in the:

Stomach? *

Yes

No

Spleen (upper left)? *

Yes

No

Liver (upper right)? *

Yes

No

Kidneys? *

Yes

No

Intestines? *

Yes

No

Abdomen? *

Yes

No

Lower back? *

Yes

No

Pelvic region? *

Yes

No