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Microsoft word - thermography intake form.doc
Thermography Clinic Inc.
BREAST HEALTH HISTORY
Name: _________________________________________ Age: _____ Date of Birth: _______________________ Address: _______________________________ City: ______________________Postal Code _________________ Home Tel: ____________________ Work Tel: _____________________ E-mail ___________________________ Occupation: __________________________________________________________________________________ Marital Status: S M D W SEP. Number of Children: _____ Referred by: _______________________________
Do you have a family history of breast cancer? r Self r Mother r Maternal Grandmother r Sister r Daughter r None
Do you have any diagnosed breast conditions? r None r Fibrocystic r Cystic r Other ______________________________________
Have you previously had a thermogram? Date of most recent _______________________ Was it: r Normal r Abnormal r Suspicious r Being watched
Have you had a mammogram? Date of most recent _______________________________ Was it: r Normal r Abnormal r Suspicious r Being watched
Have you had a breast ultrasound? Date of most recent_____________________________ Was it: r Normal r Abnormal r Suspicious r Being watched
Have you had a breast exam by a doctor? Date of most recent _______________________ Was it: r Normal r Lump Found
Any breast biopsies? When and what type (i.e. needle, core)? ___________________________
Any breast surgeries? When and what was done? ____________________
Have you had a mastectomy? When? _____________________________
Have you had radiation? When was it last performed? ________________
Have your had your ovaries removed? At what age? _______________________________
Do you have children. At what age was your first full term pregnancy? _______________
Did you nurse for at least three months? How long ________________________________
Are you currently taking birth control pills? At what age did you start? _________________ for how many years? ________________
Are you in menopause? At what age did it begin? _________________________________
Have you ever taken synthetic hormone replacement (ex. Premarin, Provera)?
Are you currently using natural progesterone cream? Applied to r Breasts only r Rotating body areas
Are you currently using herbals, homeopathic medicines, or supplements to stimulate or simulate estrogen? Explain ___________________________________________________
Do you feel that you are overweight? How many pounds overweight? _________________
Are you experiencing any of the following with your breasts?
A lump. Date found: _________________ by r Self r Doctor It is: r Hard r Soft r Mobile r Tender
Pain It is r Dull r Sharp r Burning r Stinging r Tender r Changes with my cycle
Skin changes (r Color r Texture r Over the lump)
It is r Bloody r Milky r Through one duct r through multiple ducts
Nipple changes r R r L Breast Change in: r Color r Texture
Place an [O] on the diagram in the exact area of the lump, finding on your mammogram, or area being
watched, and an [X] in the area of pain, tenderness, thickening, or skin changes.
Please note any other concerns/issues you may have: __________________________________________
General Health Information
Do you have any medical complaints or conditions? Please explain ___________________
r Y r N
Are you currently taking any medications? Please list ______________________________
Please circle all of the following conditions which you have had:
r Y r N
Are there any of the preceding conditions after which you have never been totally well again, or which have been more severe than usual? Explain? ________________________
r Y r N
Have you had any operations? Which __________________________________________
Have you lost any weight recently? How many pounds? ____________________________
Do you exercise? How often? ________________________________________________
Have you had any major injuries? Explain _______________________________________
Are you taking any of the following substances? How much?
“Recreational Drugs” _________________________
Have any of the following ailments affected your relatives? Alcoholism
Age if Alive
Age at Death
Mother: Father: Brothers: Sisters: Children: Maternal Grandmother: Maternal Grandfather: Paternal Grandmother: Paternal Grandfather:
Green-top Guideline LONG-TERM CONSEQUENCES OF POLYCYSTIC OVARY SYNDROME This is the second edition of this guideline, which was previously published in May 2003 under the same title. Purpose and scope This guideline has been produced to provide information, based on clinical evidence, to assist clinicians witha special interest and for updating the generalist who manages women with pol
NRHA General Rules and Regulations L. Animal Welfare and Medications Provisions Applicable to all NRHA Events. ((Consult legal counsel to add verbiage about state or country laws superseding NRHA rules.)) Section 1. Testing a. All horses entered in an NRHA approved class that meet the criteria of the NRHA Animal Welfare and Medications Policy are subject to examination by a licen