Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Would you like your report and images emailed to your physician or practitioner? *

Yes

No

Date of last gynecological exam *

MM

DD

YYYY

Have you received the CoVid vaccine? *

It is recommended that all thermography clients wait at least 4 weeks after their last vaccine before scheduling an appointment.

Yes

No

Date of last vaccine or booster

MM

DD

YYYY

Vaccine administered in *

Left arm

Right Arm

Not Vaccinated

Have you ever been diagnosed with any or had any of the following conditions? Please check all that apply *

Allergies

Anemia

Arthritis

Asthma

Blood Disorder

Carpal Tunnel

Chronic Fatigue

Chronic Sinusitis or Rhinitis

COPD

Crohn's Disease

Diabetes

Diverticulitis

Fibromyalgia or Chronic Fatigue

GERD

Headache or Migraine

Heart Disease

High Blood Pressure

High Cholesterol

IBS or IBD

Immune Dysfunction

Kidney Disease

Liver Disease

Lung Disease

Neuropathy

Osteoarthritis

RSD -Reflex Sympathetic Dystrophy

Spinal Stenosis

Stroke

Thyroid Disease

TMJ

Ulcerative Colitis

Numbness or Tingling in Legs

Numbness or Tingling in Arms

Herniated Disc

Other

None

Have you had any dental procedures or a dental cleaning in the last week? *

It is recommended to schedule any dental procedures, including cleanings, at least one week before your thermogram.

Yes

No

Dental Surgery History *

Extractions

Root canal

Implant

Other Surgery

None

Relatives diagnosed with breast cancer *

Mother

Sister

Maternal Aunt

Paternal Aunt

Maternal Grandmother

Paternal Grandmother

No Family History or Unknown

Have you ever been diagnosed with breast cancer? *

If yes, please complete the extended breast form.

Yes

No

Have you ever been diagnosed with any of these breast diseases? *

Fibrocystic

Mastitis

Cystic

Fibroadenoma

Papilloma

None

Have you ever had any biopsies or surgeries to your breasts? *

Yes

No

Location of breast surgery or biopsy. Please check all that apply. *

Left Breast Upper Outer

Left Breast Upper Inner

Left Breast Lower Outer

Left Breast Lower Inner

Left Breast Nipple Area

Right Breast Upper Outer

Right Breast Upper Inner

Right Breast Lower Outer

Right Breast Lower Inner

Right Breast Nipple Area

None

Date of last surgery or biopsy

MM

DD

YYYY

Have you ever had any breast cosmetic surgery, implants, augmentation, reduction, or reconstruction? *

Yes

No

Have you had a mammogram in the past 12 months? *

Yes

No

Have you had a mammogram in the past 5 years? *

Yes

No

Have you ever had any abnormal results from any breast testing? *

Please bring to your appointment or email copies of any reports from prior breast surgeries, biopsies, mammograms, sonograms, MRI or CT scans that indicated any abnormal findings.

Yes

No

Have you ever taken an oral contraceptive for more than 1 year? *

Yes

No

Have you ever been diagnosed with ovarian, uterine, or cervical cancer? *

Yes

No

Have you ever taken pharmaceutical hormone replacement therapy? *

Yes

No

Do you have an annual physical breast examination by a doctor? *

Yes

No

Do you perform a monthly breast self exam? *

Yes

No

Did your periods start before the age of 12? *

Yes

No

Did your periods end after the age of 50? *

Yes

No

I still have a menstrual cycle

Do you currently smoke, or have smoked in the past? *

Smoking includes vaping and recreational or medicinal marijuana.

Current smoker

Not smoked in last year

Not smoked in 5 years or more

Not smoked in 10 years

Not smoked in over 20 years

Never smoked

Please check if you have any of these breast symptoms *

Right breast tenderness

Left breast tenderness

Right breast lump

Left breast lump

Right breast change in size

Left breast change in size

Right breast areas of skin thickening or dimpling

Left breast areas of skin thickening or dimpling

Right breast secretions from the nipple

Left breast secretions from the nipple

None

Have you been told that you have dense breast tissue? *

Yes

No

Are you experiencing breast pain and tenderness that comes and goes? *

Yes

No

Have you had any breast lumps that come and go? *

Yes

No

Have you had chemotherapy or radiation treatment? *

Yes

No

Date of last chemotherapy or radiation treatment

MM

DD

YYYY

Is your menstrual cycle irregular? *

Yes

No

No longer have a menstrual cycle

Have you ever been diagnosed with endometriosis? *

Yes

No

N/A

Do you experience cramping during menstrual cycle? *

Yes

No

N/A

Do you observe heavy bleeding during menstrual cycle? *

Yes

No

No longer have a menstrual cycle

Have you ever been diagnosed with PCOS (poly cystic ovarian syndrome)? *

Yes

No

Have you ever been treated for infertility? *

Yes

No

Do you have low libido? *

Yes

No

Do you experience hot flashes? *

Never

Sometimes

Frequent

All the time

Do you have any swelling in the neck or trouble swallowing? *

Yes

No

Have you ever been diagnosed with any of these thyroid disorders? *

Hashimoto's

Graves Disease

Hypothyroid

Hyperthyroid

None

Do you regularly experience fatigue? *

Yes

No

Have you experienced recent hair loss? *

Yes

No

Does Thermographic Health have your permission to use texting and email as a means of communication? *

Texting would be used for appointment reminders, to clarify your health history, or for additional information concerning your thermography appointment. Our thermography reports and images are sent electronically, using a secure server. You can update and change your preferences via email or text. We value your privacy. Your email and personal information will not be shared with any third parties.

Yes, I give permission to use texting as a means of communication with Thermographic Health Advantage.

Yes, I give permission to receive copies of my reports and images via email, and as a means of communication with Thermographic Health Advantage.

Yes, I would like to receive automated email reminders for my follow-up and annual thermogram studies.

Yes, I would like to be added to Julie's email list to receive information regarding spiritual growth and personal development programs, retreats and special offers.

No, I do not give permission to use texting as a means of communication with Thermographic Health Advantage.

No, I do not give permission for Thermographic Health Advantage to send copies of my reports and images via email, or as a means of communication.

No, I do not wish to receive automated reminders for follow-up and annual thermography studies.

PATIENT DISCLOSURE *

I understand that the Report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis, and treatment. I further understand that the Thermography 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 be an analysis of the Images with respect only to the Thermographic findings discussed in the report. Breast thermography screening is an adjunctive test to mammography, ultrasound, and MRI and is a specialized physiological test designed to detect angiogenesis, hyperthermia from nitric oxide, estrogen dominance, lymph abnormality, and inflammatory processes including inflammatory breast disease, all of which cannot be detected with structural tests.

By checking this box, I certify that I have read and understand the statements above and consent to the examination and that the above information is correct to my knowledge.