Home
Services
Appointments
FAQ
About
Links and Articles
Contact
Thermographic Health Advantage
Preventative Health Screening Designed for Your Well-Being
Home
Services
Appointments
FAQ
About
Links and Articles
Contact
Menu
Extended Breast Questionnaire
This form is necessary
only
if you have a history or diagnosis of
breast cancer.
Name
*
First Name
Last Name
Email Address
*
Date of birth
*
MM
DD
YYYY
Breast cancer diagnosis
*
Please bring a copy of all biopsy, surgical, mammography, sonogram, MRI, or CT scan reports, concerning your cancer diagnosis with you to your appointment.
Cancer type:
*
ALH - Atypical lobular hyperplasia
DCIS - Ductal carcinoma in situ
IDC - Invasive ductal carcinoma
LCI - Lobular carcinoma in-situ
ILC - Invasive lobular carcinoma
Metastatic stage 4 breast cancer
Triple-negative breast cancer
Inflammatory breast cancer
Paget disease of the breast
Angiosarcoma
Phyllodes tumor
Metaplastic carcinoma
HER2-positive breast cancer
Location of cancer or lump. Please check all that apply
*
Left Breast - Upper Outer
Left Breast - Upper Inner
Left Breast - Lower Outer
Left Breast - Lower Inner
Left Breast - Nipple/Areola
Right Breast - Upper Outer
Right Breast - Upper Inner
Right Breast - Lower Outer
Right Breast - Lower Inner
Right Breast - Nipple/Areola
Biopsies or surgeries to the breast. Please check all that apply
*
Left Breast - Upper Outer
Left Breast - Upper Inner
Left Breast - Lower Outer
Left Breast - Lower Inner
Left Breast - Nipple/Areola
Right Breast - Upper Outer
Right Breast - Upper Inner
Right Breast - Lower Outer
Right Breast - Lower Inner
Right Breast - Nipple/Areola
Thank you!