Women's Breast Study Questionnaire Required fields are marked with * Contact Information * Enter your name * Enter your phone number (numbers only) * Enter your email address Please enter a valid email address. * Address * Birthday How did you hear about Thermal Imaging Center? - Select - Online Search Facebook Instagram Health Fair/Expo Doctor/Provider Friend/Relative Returning Client Other Name of the person who referred you? Specific Reason Is there a specific reason for this exam? Breasts Have you recently had any of these breast symptoms? Pain/Tenderness Left Right Lumps Left Right Change in breast size Left Right Areas of skin changes thickening or dimpling Left Right Excretions or changes of the nipple Left Right * Are any of the above symptoms cycle related? Yes No * Are you still having your periods? Yes No Date of the first day of your last cycle? * Have you had a surgical hysterectomy? Yes No When? Extent Complete Partial Reason(s) for hysterectomy? Excess bleeding Endometriosis Fibroid cysts Cancer Other * Has anyone in your family ever been treated for breast cancer? Yes No Who? Grandmother Mother Sister Daughter Age Diagnosed? Result of treatment? * Have you ever been diagnosed with breast cancer? Yes No When? Cancer type? Local Metastatic Lymph node involvement Left breast: Inner Outer Nipple Right breast: Inner Outer Nipple Treatment(s): Surgery Chemo Radiation None Other * Have you ever been diagnosed with any other breast disease? Yes No Type(s)? Cysts/fibrocystic Fibroadenoma Mastitis/Inflammatory breast disease * Have you had any cosmetic breast surgery or implants? Yes No When? Type? Silicone Saline How did it go? Had problems No problems * Have you ever had any biopsies or any other surgeries to your breasts? Yes No When? Left breast: Inner Outer Nipple Right breast: Inner Outer Nipple Results: Negative Positive Calcifications * Have you ever taken contraceptive pills for more than one year? Yes No * Have you had pharmaceutical hormone replacement therapy (HRT)? Yes No Duration? Less than 5 years More than 5 years Not applicable * Do you have an annual physical examination by a doctor? Yes No * Do you perform a monthly breast self exam? Yes No * Have you ever smoked? Yes No * Have you ever been diagnosed with diabetes? Yes No * Have you ever had a mammogram? Yes No Total mammograms: Date of last mammogram: Were you re-called? Yes No Your age at your first mammogram? Number of full-term pregnancies? * Have you had breast ultrasound? Yes No When? Which breast? Left Right Result? Positive Negative * Have you had breast MRI? Yes No When? Which breast? Left Right Result? Positive Negative
