Please complete the document below only if you are having a Thermographic Breast Study, or the Women's Wellness Study.

Name *
Name
Do you you have any relatives with breast cancer? *
Have you ever been diagnosed with breast cancer? *
Have you ever been diagnosed with any other breast disease? (fibrocystic, mastitis, fibroadenoma, cysts, papillomas) *
Have you had any surgeries or biopsies to your breasts? *
Have you had any breast cosmetic surgery or implants? (augmentation, reduction, reconstruction, implants) *
Have you had a mammogram in the past 12 months? *
Have you had a mammogram in the past 5 years? *
Have you had any abnormal results from any breast testing? *
Have you ever taken a contraceptive pill for more than one year? *
Have you ever been diagnosed with a cancer of the womb? (cervical, uterine or endometrial) *
Have you ever taken pharmaceutical hormone replacement therapy? *
Do you have an annual physical examination by a doctor? *
Do you perform monthly self breast exams? *
Did your period begin before the age of 12? *
Have your periods stopped? *
Do you smoke? *
Please check if you have any of these breast symptoms?
I understand that the Report generated from my thermographic images is intended for use by trained health care providers to assist in evaluation, diagnosis and 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 any illness, disease or other condition, but will provide 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 and I affirm that the above information is correct to the best of my knowledge. 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.
By checking the box below, I certify that I have read and understand the statements above and consent to the examination. *