Thermography Women's Health Check
Thermography Initial Health History & Consent
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Email *
Emergency contact: Full name and mobile number.
Full Name *
Today's Date *
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Your Birth Date
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Current Address *
Moble Cell phone number *
Occupation *
HIPAA CLIENT CONFIDENTIALITY AND RELEASE FORM.  PLEASE READ AND SIGN BELOW:  I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.  Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance.  HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation.  Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records (Please sign and date below to confirm you have read the above HIPAA CLIENT CONFIDENTIALITY AND RELEASE). *
SYMPTOMS & HISTORY
Age/Gender *
Primary Care Physician: *
Referring Physician: *
Clinical Concerns: *
Current Symptoms: *
Current Treatment: *
Current Medications: *
THERMOGRAPHY HISTORY:  Have you ever had Thermography?  If so, how many and what dates?  Any abnormal results from past scans? *
SURGICAL HISTORY:  Please list your surgeries and dates. *
DENTAL HISTORY:  Please list dental procedures and dates. *
GENERAL HISTORY:  Please list any relevant general history and dates. *
FAMILY HISTORY:  Please list any relevant immediate family history and dates. (mother, father, siblings, grandparents) *
DIAGNOSES:  Please list any relevant diagnosis from a doctor and dates. *
SKIN LESIONS OR PHYSICAL ABNORMALITIES: Please list any relevant issues and dates. *
OB/GYN HISTORY
How many times have you been pregnant? What was your age at your first pregnancy? *
How many live births have you had and were they vaginal or surgical?   Please list dates.   *
How many miscarriages or terminations?  Please list dates. *
Have you ever had any sexually transmitted infections?  Please list dates. *
Have you ever had any surgeries in the pelvic bowl?  Please list dates. *
MAMMOGRAM HISTORY
Have you ever had a mammogram?  Please list how many and the dates. *
Any abnormal results from Mammogram screening?
WOMENS HEALTH CHECK QUESTIONNAIRE
Any close relatives ever have breast cancer?  If you do not know your family history please choose other.
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Ever been diagnosed with breast cancer? *
Ever been diagnosed with any other breast disease? *
Ever had any biopsies or surgeries to breasts? *
Ever have any breast cosmetic surgery or implants? *
Do you have dense breast tissue?
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Had a mammogram in the past 12 months? *
Had more than 30 mammogram in your life time? *
Had a Mammogram in the past 5 years? *
Had any abnormal results from any breast testing? *
Ever taken a contraceptive or more than 4 years? *
Ever been diagnosed with ovarian, uterine or cervical cancer? *
Ever had hormone replacement therapy? *
Have an annual physical breast examination by a doctor? *
Perform a monthly breast self-exam? *
Periods start before the age of 12? *
Periods end after the age of 50? *
Ever given birth to a child? *
Ever smoked for more than 5 years? *
Is menstrual cycle irregular? *
Experience cramping during your menstrual cycle? *
Observe heavy bleeding during menstrual cycle? *
Breast pain and tenderness that comes and goes? *
Do you have low libido? *
Do you have hot flashes? *
Ever been diagnosed with endometriosis? *
Ever been diagnoses with PCOS (poly cystic ovarian syndrome?) *
Ever been treated for infertility? *
Do you have any swelling in the neck or trouble swallowing? *
Ever been diagnosed with any thyroid disorder? *
Do you regularly experience fatigue? *
Have you experienced recent hair loss? *
Had vaccination in the past 4 weeks?  If yes please indicate which arm below in "other" option? *
Have you recently had any of these breast symptoms? *
Right
Left
Both
N/A
Pain?
Tenderness?
Lumps?
Changes in breast size?
Areas of skin thickening or dimpling?
Secretions of the nipple?
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