Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Phone

(###)

###

####

Do you want a copy of the Thermogram report forwarded to your doctor?

Yes

No

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

Yes

Do you have any close relative who has had breast cancer?

Yes

No

Have you ever been diagnosed with breast cancer?

Yes

No

Have you ever been diagnosed with any other breast disease (fibrocystic)?

Yes

No

Have you had any biopsies or surgeries to your breasts?

Yes

No

Have you had abnormal results from any breast testing?

Yes

No

Do you have an annual physical examination by a doctor?

Yes

No

Do you smoke?

Yes

Never

Not in last 12 months

Not in last 5 years

Have you recently had any of these breast symptoms?

Pain in right breast

Pain in left breast

Tenderness in right breast

Tenderness in left breast

Lumps in right breast

Lumps in left breast

Change in breast size - right

Change in breast size - left

Areas of skin thickening or dimpling - right

Areas of skin thickening or dimpling - left

Secretions of the right nipple

Secretions of the left nipple

The following questions apply if you were diagnosed with breast cancer. Cancer type:

Metastatis

Local

Lymph node involvement

Where (left breast):

UO

UI

LO

LI

Nipple

Where (right breast):

UO

UI

LO

LI

Nipple

Treatment

Surgery

Chemo

Radiation

Other

None

Diagnosed with other breast disease (Please report other types of disease in the history). Indicate disease type:

Fibrocystic

Cystic

Mastitis

Abscess

Other

Breast biopsies or surgery. Where (left breast):

UO

UI

LO

LI

Nipple

Where (right breast):

UO

UI

LO

LI

Nipple