MEDICAL INFRARED THERMOGRAPHY
Breast Health History

Name: _________________________________________ Age: _____ Date of Birth: ________________ Address: _______________________________ City: ___________________ Postal Code ____________ Home Tel: ____________________ Work Tel: _____________________ E-mail ___________________ Marital Status: S M D W SEP. Number of Children: _____ Referred By: _____________________________________________________

? Y ? N Do you have a family history of breast conditions?

? Self ? Mother ? Grandmother ? Sister ? Daughter ? None ? Y ? N Do you have any diagnosed breast conditions?

? None ? Fibrocystic ? Cystic ? Other ______________________________________ ? Y ? N Have you previously had a thermogram? Date of most recent ____________________________________________

Was it: ? Normal ? Abnormal ? Suspicious ? Being watched ? R ? L Breast ? Y ? N Have you had a mammogram? Date of most recent ________________________________________________________________

Was it: ? Normal ? Abnormal ? Suspicious ? Being watched ? R ? L Breast ? Y ? N Have you had an ultrasound? Date of most recent __________________________________________________________________

Was it: ? Normal ? Abnormal ? Suspicious ? Being watched ? R ? L Breast ? Y ? N Have you had a breast exam by a doctor? Date of most recent ________________________________________________________

Was it: ? Normal ? Lump Found ? R ? L Breast ? Y ? N Any breast biopsies?

When and what type (i.e. needle, core)? ___________________________ ? R ? L Breast ? Y ? N Any breast surgeries? When and what was done? ____________________ ? R ? L Breast ? Y ? N Have you had a mastectomy? When? _____________________________ ? R ? L Breast ? Y ? N Have you had radiation? When was it last performed? ________________ ? R ? L Breast ? Y ? N Have your had your ovaries removed? At what age? _______________________________ ? Y ? N Do you have children. At what age was your first full term pregnancy? _______________ ? Y ? N Did you nurse for at least three months? How long ________________________________ ? Y ? N Are you currently nursing? ? Y ? N Are you currently pregnant? ? Y ? N Are you currently taking birth control pills?

At what age did you start? _________________ for how many years? ________________ ? Y ? N Are you in menopause? At what age did it begin? _________________________________ __________________________________________________________________

? Y	? N	Have you ever taken synthetic hormone replacement (ex. Premarin, Provera)?
		How many years taken? ____________
? Y	? N	Are you currently using natural progesterone cream?
		Applied to ? Breasts only ? Rotating body areas
? Y	? N	Are you currently using herbals, homeopathic medicines, or supplements to stimulate or
		simulate estrogen? Explain ___________________________________________________
? Y	? N	Do you feel that you are overweight? How many pounds overweight? _________________
		Are you experiencing any of the following with your breasts:
? Y	? N	A lump. Date found: _________________ by ? Self ? Doctor
		It is: ? Hard ? Soft ? Mobile ? Tender
? Y	? N	Pain
		It is ? Dull ? Sharp ? Burning ? Stinging ? Tender ? Changes with my cycle
? Y	? N	Thickening
? Y	? N	Skin changes (? Color ? Texture ? Over the lump)
? Y	? N	Nipple discharge	? R ? L Breast
		It is ? Bloody ? Milky ? Through one duct ? through multiple ducts
? Y	? N	Nipple retraction	? R ? L Breast
? Y	? N	Nipple changes	? R ? L Breast
		Change in: ? Color ? Texture
? Y	? N	Other

 

Place an [O] on the diagram in the exact area of the lump, finding on your mammogram, or area being watched, and an [X] in the area of pain, tenderness, thickening, or skin changes.

RIGHT BREAST LEFT BREAST

Please note any other concerns/issues you may have: __________________________________________

General Health Information

? Y ? N Do you have any medical complaints or conditions? Please explain ___________________ ? Y ? N
Are you currently taking any medications? Please list ______________________________

Please circle all of the following conditions which you have had:

Abscesses	Depression	Heart Disease	Mononucleosis	Rheumatic Fever				Syphilis
Addiction	Diabetes	Hepatitis	Mumps	Rubella				Tonsillitis
Allergies	Emphysema	Herpes Genitalia	Parasites	Scarlet Fever				Tuberculosis
Amnesia	Epilepsy	Influenza	Pelvic Inflammatory Sexual Abuse				Typhoid Fever
Arthritis	Gall Stones	Kidney Disease	Disease	Skin Disease	Venereal Warts
Asthma	Goiter	Leukemia	Peritonitis	Strep Throat	Warts
Cancer	Gonorrhea	Malaria	Pleurisy	Sinusitis	Whooping Cough
Chicken Pox	Gout	Measles	Pneumonia	Sunstroke		Worms
Cold Sores	Hay Fever	Miscarriage	Prostatitis	Stroke		Yellow Fever

Other ________________________________________________________________________________ ? Y ? N Are there any of the preceding conditions after which you have never been totally well again, or which have been more severe than usual? Explain? ________________________ ? Y ? N Have you had any operations? Which __________________________________________ ? Y ? N Have you lost any weight recently? How many pounds? ____________________________ ? Y ? N Do you exercise? How often? ________________________________________________ ? Y ? N Have you had any major injuries? Explain _______________________________________ ? Y ? N Are you taking any of the following substances? How much? Tobacco: _____________________ Alcohol: ____________________________________ Coffee: _____________________ “Recreational Drugs” _________________________ ? Y ? N Have any of the following ailments affected your relatives? Alcoholism Asthma Diabetes Gout Mental Illness Skin Disease Allergies Cancer Epilepsy Hay Fever Paralysis Syphilis Arthritis Depression Gonorrhea Heart Disease Pneumonia Tuberculosis