Thermal Imaging Center | Thermography

Men's Health Study Questionnaire

Required fields are marked with *

* 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?

Name of the person who referred you?

Is there a specific reason for this exam?

* Do you suffer with headaches? Yes No

* Do you have known allergies? Yes No

* Do you have TMJ or does your jaw click? Yes No

* Do you currently have a cold? Yes No

* Are you being treated for a thyroid disorder? Yes No

* Do you have neck pain? Yes No

* Do you suffer with upper back pain? Yes No

* Do you have a known history of carotid artery disease? Yes No

* Do you have a family history of stroke? Yes No

* Do you currently suffer with sinus problems? Yes No

* Do you have history of dental problems? Yes No

* Have you had dental cleaning in the past 7 days? Yes No

* Have you ever been diagnosed with high cholesterol? Yes No

Have you been diagnosed with: * Heart disease? Yes No * Lung disease? Yes No * Upper spine disorders? Yes No

* Do you suffer with chest pain? Yes No

Have you ever had surgery to your: * Heart? Yes No * Lungs? Yes No * Mid to upper back? Yes No

* Do you have asthma or shortness of breath? Yes No

* Do you currently smoke? Yes No

* Have you smoked in the past 5 years? Yes No

* Have you consumed alcohol in the past 24 hours? Yes No

* Do you suffer with acid reflux or other digestive problems? Yes No