Microsoft word - thermography intake form.doc

Thermography Clinic Inc.
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 Other __________________________________________________________________ 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:

Other ________________________________________________________________________________
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?
Tobacco: _____________________
Alcohol: ___________________________________ “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:


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