Holistic Wellness Center | Northwest Healing Center | United States
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Contact 224 600-3216 224 600-3216
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Patient Information

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All information given in the questionnaire will remain strictly confidential and will only be divulged to the
reporting thermologist and any other practitioner that you specify.

Select one(Required)

Patient Information Sheet.

Family History

Dental history, Do you have any crowns, root canals, or metal fillings? If yes, where are they located?
Have you had a vaccination in the last 4 week? If yes, which arm, Right or Left?

You will be emailed your report and you can send a copy of the thermogram report to your doctor or caregivers.
This information is confidential.

BREAST CONFIDENTIAL QUESTIONNAIRE

1. Do you have a close relative who has had breast cancer?
2. Have you ever been diagnosed with breast cancer?
If NO skip to question 11
4. Cancer type:
5. Where (Left breast):
Where (Right breast):
6. Treatment
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If breast radiation treatment
9. Any breast reconstruction after mastectomy?
10. If yes, what type? (ex: trans flap, implant)
11. Have you ever been diagnosed with any other breast disease?
If YES, what type:
12. Have you had any biopsies or lumpectomies to your breasts?
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Result:
Where (Left breast):
Where (Right breast):
13. Have you had cosmetic breast surgery (implants/ reduction/ lift)?
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14. Are you currently nursing?
15. Are you currently pregnant?
16. Have you had a mammogram in the past 12 months?
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Results:
17. Have you had a mammogram in the past 5 years?
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Results:
18. Have you had an ultrasound in the past 12 months?
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Results:
19. Have you had an ultrasound in the past 5 years?
Results:
20. Was follow‐up biopsy recommended after your most recent mammogram, ultrasound, or MRI?
21. Have you had any abnormal results from any breast testing?
22. Have you ever taken a contraceptive pill/patch for more than a year?
23. Have you ever taken a contraceptive pill/patch for more than 4 years?
24. Have you had pharmaceutical hormone replacement therapy?
If yes
Have you used bio‐identical hormone?
25. Have you been diagnosed w/ ovarian, cervical or uterine cancer?
26. Have you had a:
27. Do you have an annual Breast physical examination by a doctor?
28. Do you perform a monthly breast self‐exam?
Have you had more than 30?
33. Did you start your period before the age of 12?
34. Are you still having a monthly period?
35. Did your periods finish after the age of 50?
36. Do you smoke?
Dense Breasts
38. Have you RECENTLY/ CURRENTLY experienced any of these breast symptoms? (If yes, please mark which breast)
Pain?
Tenderness?
Change in breast size?
Lumps?
Secretions of the nipples?
Areas of skin thickening or dimpling?
If experiencing nipple discharge – is it
If nipple retraction:

PATIENT DISCLOSURE: I understand that the Report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis & treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have an illness, disease, or other condition 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 statements above and consent to the examination.

Is your menstrual cycle regular?
Do you have heavy bleeding with your menstrual cycle?
Do you have cramping with your menstrual cycle?
Do you have lumps in your breasts that come and go?
Do you have breast pain and tenderness that come and go?
Do you experience pre-menstrual headaches?
Do you have low libido?
Do you have hot flashes?
Do you experience mood swings?
Have you ever been diagnosed with endometriosis?
Have you ever been diagnosed with PCOS (polycystic ovarian syndrome)?
Have you ever been treated for infertility?
Have you had difficulty conceiving?
Do you have any swelling in the neck or trouble swallowing?
Have you been diagnosed with any thyroid disorder?
If yes what type:
Are you on a thyroid medication or supplement?
Do you regularly experience fatigue?
Have you experienced recent hair loss?
Have you experienced unexplained weight gain?
Have you experienced unexplained weight loss?
Are you intolerant to cooler temperatures/ sensitive to cold?
Do you experience chronic insomnia?
Do you experience chronic brain fog?

Full Body Study Questionnaire

All information given in the questionnaire will remain strictly confidential and will only be released to the reporting thermologist and any other practitioner that you specify.

Authorization to Use or Disclose Protected Health Information

Northwest Medical Thermography
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As required by the Privacy Regulations, Northwest Medical Thermography may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

EMI, Electronic Medical Interpretations

Patient Health Information authorized to be disclosed: Thermal Images and related health history



For the specific purpose of (describe in detail)

Interpretation of said images

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Authorization will expire one year from date signed


I understand I have the right to:

1. Revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization.

2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as are result of this authorization.

3. Inspect a copy of Patient Health Information being used or disclosed under federal law.

4. Refuse to sign this authorization.

5. Receive a copy of this authorization.

6. Restrict what is disclosed with this authorization.


I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.

Business info

Northwest Medical Screening

Address: 22000 N. Pepper Rd. Lake Barrington IL 60010
Phone: (224) 600-3216
Email:
hello@northwesthealingcenter.com
Hours: Mon –
Fri: 9AM – 7PM
Sat: 8AM – 2PM
Sun: CLOSED

Services

Thermography

AO Total Body Scan

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