Women's Full Body 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? Head & Neck * Do you suffer with headaches? Yes No How many per month? * Do you have known allergies? Yes No What type? Food Environmental * 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 Type? * 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 What type? Root Canal Gum Disease Implant * Have you had dental cleaning in the past 7 days? Yes No * Have you ever been diagnosed with high cholesterol? Yes No 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 Chest, Heart & Lungs 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 Abdomen & Lower Back * Do you suffer with acid reflux or other digestive problems? Yes No Do you suffer with 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 Arms & Hands Do you suffer pain in the: Shoulder? Left Right Elbow? Left Right Arm? Left Right Hand? Left Right Have you had Surgery to: Shoulder? Left Right Elbow? Left Right Arm? Left Right Hand? Left Right
