Contact Information

Enter your name *

Phone *

Enter your email address *

Address *

Enter your home address

Birthday *

Select the month of your birthdate

*

Type the day of your birthdate

*

Type the year of your birthdate

How did you hear about Thermal Imaging Center? *

Name of person who referred you?

Specific Reason

Is there a specific reason for this exam?

Abdomen & Lower Back

Do you suffer with acid reflux or other digestive problems? *

Yes

No

Do you suffer pain in the:

Stomach? *

Yes

No

Below right breast? *

Yes

No

Below left breast? *

Yes

No

Abdomen? *

Yes

No

Lower back? *

Yes

No

Pelvic region? *

Yes

No

Have you had surgery or disease in the:

Stomach? *

Yes

No

Spleen (upper left)? *

Yes

No

Liver (upper right)? *

Yes

No

Kidneys? *

Yes

No

Intestines? *

Yes

No

Abdomen? *

Yes

No

Lower back? *

Yes

No

Pelvic region? *

Yes

No

Legs & Feet

Do you suffer pain in the:

Leg?

Left

Right

Sciatica?

Left

Right

Buttocks/hip?

Left

Right

Knee?

Left

Right

Ankle?

Left

Right

Foot?

Left

Right

Have you had Surgery to:

Leg?

Left

Right

Sciatica?

Left

Right

Buttocks/hip?

Left

Right

Knee?

Left

Right

Ankle?

Left

Right

Foot?

Left

Right