Step 1 of 6 16% Patient InformationFirst Name(Required) Last Name*(Required) Birthdate MM slash DD slash YYYY Address City Zip PhoneEmail*(Required) Your Doctor 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) Male Female Patient Information Sheet.Previous Illnesses. Previous Surgeries and date when it happened? Current Health Problems and when did they start? Family HistoryMaternal family: Paternal family: Dental history, Do you have any crowns, root canals, or metal fillings? If yes, where are they located? Yes No 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? Yes No Have you had a vaccination in the last 4 week? If yes, which arm, Right or Left? Medication. Other Treatment. Current Doctor. 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 QUESTIONNAIRE1. Do you have a close relative who has had breast cancer? Yes No Relationship: 2. Have you ever been diagnosed with breast cancer? Yes No If NO skip to question 113. If YES, when: 4. Cancer type: Metastatic Local Lymph node involvement 5. Where (Left breast): Upper/Outer Upper/Inner Lower/Outer Lower/Inner Nipple Select AllWhere (Right breast): Upper/Outer Upper/Inner Lower/Outer Lower/Inner Nipple Select All6. Treatment None Surgery Chemotherapy Radiation Select All7. If breast radiation treatment – date of last treatment? MM slash DD slash YYYY If breast radiation treatment Right breast Left breast 8. Any other treatment? 9. Any breast reconstruction after mastectomy? Yes No 10. If yes, what type? (ex: trans flap, implant) 10. If yes, what type? (ex: trans flap, implant) Right breast Left breast 11. Have you ever been diagnosed with any other breast disease? Yes No Abscess Other If YES, what type: Fibrocystic Cystic Mastitis Dense breast tissue 12. Have you had any biopsies or lumpectomies to your breasts? Yes No Date: MM slash DD slash YYYY Result: Positive Negative Where (Left breast): Upper/Outer Upper/Inner Lower/Outer Lower/Inner Nipple Where (Right breast): Upper/Outer Upper/Inner Lower/Outer Lower/Inner Nipple 13. Have you had cosmetic breast surgery (implants/ reduction/ lift)? Yes No Date: MM slash DD slash YYYY 14. Are you currently nursing? Yes No 15. Are you currently pregnant? Yes No 16. Have you had a mammogram in the past 12 months? Yes No Date: MM slash DD slash YYYY Results: Normal Abnormal Suspicious Inconclusive Right breast Left breast Select All17. Have you had a mammogram in the past 5 years? Yes No Approx Date: MM slash DD slash YYYY Results: Normal Abnormal Suspicious Inconclusive Right breast Left breast Select All18. Have you had an ultrasound in the past 12 months? Yes No Date: MM slash DD slash YYYY Approx Date: MM slash DD slash YYYY Results: Normal Abnormal Suspicious Inconclusive Right breast Left breast Select All19. Have you had an ultrasound in the past 5 years? Yes No Results: Normal Abnormal Suspicious Inconclusive Right breast Left breast Select All20. Was follow‐up biopsy recommended after your most recent mammogram, ultrasound, or MRI? Yes No 21. Have you had any abnormal results from any breast testing? Yes No 22. Have you ever taken a contraceptive pill/patch for more than a year? Yes No If YES, briefly explain: 23. Have you ever taken a contraceptive pill/patch for more than 4 years? Yes No 24. Have you had pharmaceutical hormone replacement therapy? Yes No If yes gel/cream oral pellet Have you used bio‐identical hormone? Yes No 25. Have you been diagnosed w/ ovarian, cervical or uterine cancer? Yes No If yes when? 26. Have you had a: Hysterectomy Oophorectomy (ovaries) Total/ radical hysterectomy (Uterus+Ovaries+Tubes) 27. Do you have an annual Breast physical examination by a doctor? Yes No 28. Do you perform a monthly breast self‐exam? Yes No 29. How many mammograms have you had in total? Have you had more than 30? Yes No 30. What was your age when you had your first mammogram? 31. How many times have you been pregnant? 32. What was your age when your first child was born? 33. Did you start your period before the age of 12? Yes No 34. Are you still having a monthly period? Yes No 35. Did your periods finish after the age of 50? Yes No 36. Do you smoke? Yes Never Not in last 12 months Not in last 5 years For more than 5 years Dense Breasts Yes No 38. Have you RECENTLY/ CURRENTLY experienced any of these breast symptoms? (If yes, please mark which breast)Pain? Left breast Right breast Tenderness? Left breast Right breast Change in breast size? Left breast Right breast Lumps? Left breast Right breast Secretions of the nipples? Left breast Right breast Areas of skin thickening or dimpling? Left breast Right breast If experiencing nipple discharge – is it Bloody Milky Clear If nipple retraction: For many years? Recently? Left breast Right breast 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? Yes No Do you have heavy bleeding with your menstrual cycle? Yes No Do you have cramping with your menstrual cycle? Yes No Do you have lumps in your breasts that come and go? Yes No Do you have breast pain and tenderness that come and go? Yes No Do you experience pre-menstrual headaches? Yes No Do you have low libido? Yes No Do you have hot flashes? Yes No Do you experience mood swings? Yes No Have you ever been diagnosed with endometriosis? Yes No Have you ever been diagnosed with PCOS (polycystic ovarian syndrome)? Yes No Have you ever been treated for infertility? Yes No Have you had difficulty conceiving? Yes No Do you have any swelling in the neck or trouble swallowing? Yes No Have you been diagnosed with any thyroid disorder? Yes No If yes what type: Hypothyroid Hyperthyroid Hashimoto's Grave's disease Are you on a thyroid medication or supplement? Yes No What kind? Do you regularly experience fatigue? Yes No Have you experienced recent hair loss? Yes No Have you experienced unexplained weight gain? Yes No Have you experienced unexplained weight loss? Yes No Are you intolerant to cooler temperatures/ sensitive to cold? Yes No Do you experience chronic insomnia? Yes No Do you experience chronic brain fog? Yes No Full Body Study QuestionnaireAll 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.Please list any areas where you feel pain, secondary pain, numbness, pins and needles, skin lesions or scaringDo you know what triggered the pain ? Does anything relieve it ? Does anything aggravate it ? Has it changed since it began ? Have you had any treatment ? History: Injuries / Fractures / Surgery Authorization to Use or Disclose Protected Health InformationNorthwest Medical ThermographyPatient Name: Address: Date of Birth: MM slash DD slash YYYY Date of Request: MM slash DD slash YYYY 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 Effective date for this authorization: MM slash DD slash YYYY 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.
