THERMOGRAPHY CLINIC 1596 REGENT ST. SUDBURY, ON P3E 3Z6

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Transcription:

THERMOGRAPHY CLINIC 1596 REGENT ST. SUDBURY, ON P3E 3Z6 HEALTH HISTORY Name: Age: Date of Birth: Address: City: Postal Code Home Tel: Work Tel: E-mail Occupation: Marital Status: S M D W SEP. Number of Children: Referred By: -------------------------------------------------------------------------------------------------------------------------------- Do you have a family history of breast cancer? r Self r Mother r Grandmother r Sister r Daughter r None Do you have any diagnosed breast conditions? r None r Fibrocystic r Cystic r Other Have you previously had a thermogram? Date of most recent Have you had a mammogram? Date of most recent Have you had an ultrasound? Date of most recent Have you had a breast exam by a doctor? Date of most recent Was it: r Normal r Lump Found r R r L Breast Any breast biopsies? When and what type (i.e. needle, core)? r R r L Breast Any breast surgeries? When and what was done? r R r L Breast Have you had a mastectomy? When? r R r L Breast Have you had radiation? When was it last performed? r R r L Breast Have your had your ovaries removed? At what age? Do you have children. At what age was your first full term pregnancy? Did you nurse for at least three months? How long

Are you currently nursing? Are you currently pregnant? Are you currently taking birth control pills? At what age did you start? for how many years? Are you in menopause? At what age did it begin? Have you ever taken synthetic hormone replacement (ex. Premarin, Provera)? How many years taken? Are you currently using natural progesterone cream? Applied to r Breasts only r Rotating body areas Are you currently using herbals, homeopathic medicines, or supplements to stimulate or simulate estrogen? Explain Do you feel that you are overweight? How many pounds overweight? Are you experiencing any of the following with your breasts? A lump. Date found: by r Self r Doctor It is: r Hard r Soft r Mobile r Tender Pain It is r Dull r Sharp r Burning r Stinging r Tender r Changes with my cycle Thickening Skin changes (r Color r Texture r Over the lump) Nipple discharge r R r L Breast It is r Bloody r Milky r Through one duct r through multiple ducts Nipple retraction r R r L Breast Nipple changes r R r L Breast Change in: r Color r Texture Place an [O] on the following 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 Do you have any medical complaints or conditions? Please explain 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 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? Have you had any operations? Which Have you lost any weight recently? How many pounds? Do you exercise? How often? Have you had any major injuries? Explain Are you taking any of the following substances? How much? Tobacco: Alcohol: Coffee: Recreational Drugs 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

PRE-EXAMINATION INSTRUCTIONS In order to ensure that your images are diagnostic, the following instructions must be adhered to: Do not wear restrictive clothing such as a bra to the exam. Tie your hair up and do not wear jewelry around the neck area (just for the imaging). No prolonged sun exposure (especially sunburn) to the breasts 5 days prior to your exam. No use of lotions, creams, powders, or makeup on the breasts the day of the exam. No use of deodorants or antiperspirants the day of your exam. No physical stimulation (sexual or otherwise) or treatment of the breasts for 24 hours before the exam. No treatment (chiropractic, acupuncture, massage, physical therapy, electrical muscle stimulation, ultrasound, hot or cold pack use) of the neck, back, chest or breasts for 24 hours before the exam. No exercise 4 hours prior to your exam. No shaving on the day of the exam to avoid skin abrasions. If bathing, it must be no closer than 1 hour before the exam. If you are nursing, please try to nurse as far from 1 hour before the exam as possible. No warm or cold beverages 2 hours prior to imaging. Do not drink alcohol 12 hours prior to the test. No smoking at least 1 hour before imaging. If you are using pain medications, please avoid taking them for 4 hours prior to the examination. You must consult with your prescribing physician for his/her consent prior to any change in medication use such as this. Please note: During the examination you will disrobe from the waist up for both imaging and to allow for the surface temperature of the body to acclimate with the room. A female technician will take your images. Surgical procedures such as implants, reductions, and biopsies do not interfere with infrared imaging. Breast infrared imaging is perfectly 100% safe to have during pregnancy or when nursing.

If you have copies of any other test results (e.g. mammograms, ultrasounds, biopsies) please bring them with you. The total time necessary to complete your breast thermography examination is approximately 30 minutes. Upper body thermography examinations are 45 minutes, and full body scans are 1 hour. If you have any further questions, please feel free to contact our office at 705-568- 7873. You will be requested to sign a thermography consent form before proceeding with imaging. I have read and understood and will comply with the instructions above. Name Signature Date

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