Womens_Health_Check_Questionnaire

Confidential Questionnaire for Women's Health Check
NAME
Date of Birth

Month Day Year
Date
Please mark YES or NO as it applies to you:
Any close relative ever had breast cancer?

Yes No
Ever been diagnosed with breast cancer?

Left Right Yes No
Date

Month Day Year
Date
Diagnosed with any other breast disease? (Fibrocystic, Mastitis, Cystic, Abscess)

Yes No
Any biopsy or surgery to your breasts?

Left Right Yes No
Date

Month Day Year
Date
Cosmetic surgery to breasts? (Implants, reduction, lift)

Left Right Yes No
Date

Month Day Year
Date
Do you have dense breast tissue?

Yes No
Have you had a mammogram in the past 12 months?

Yes No
Have you had more than 30 mammograms in your lifetime?

Yes No
Mammogram in the past 5 years?

Yes No
Date

Month Day Year
Date
Any abnormal results from any breast testing?

Yes No
Ever taken a contraceptive pill for more than 4 years?

Yes No
How Long?
Ever diagnosed with ovarian, uterine or cervical cancer?

Yes No
Ever taken hormone replacement therapy? (Pharmaceutical or bio-identical)

Yes No
Do you have an annual physical breast examination by adoctor?

Yes No
Do you perform a monthly breast self-exam?

Yes No
Did your periods start before the age of 12?

Yes No
Did your periods end after the age of 50?

Yes No
Are you still having a menstrual cycle?

Yes No
Have you ever given birth to a child?

Yes No
Have you ever smoked for more than 5 years?

Yes No
Is your menstrual cycle irregular?

Yes No
Do you experience cramping during your menstrual cycle?

Yes No
Do you have heavy bleeding with your menstrual cycle?

Yes No
Do you have breast tenderness that comes and goes?

Yes No
Do you have any breast lumps that come and go?

Yes No
Do you have low libido? (low sex drive?)

Yes No
Do you have hot flashes?

Yes No
Have you ever been diagnosed with endometriosis?

Yes No
Have you ever been diagnoses with PCOS (poly cystic ovarian syndrome)?

Yes No
Have you ever been treated for infertility?

Yes No
Do you have any swelling in the neck or trouble swallowing?

Yes No
Any thyroid disorder? (hypothyroid/ hyperthyroid/ Hashimoto’s/ Grave’s disease)

Yes No
Do you regularly experience fatigue?

Yes No
Have you experienced recent hair loss?

Yes No
Mark Right Breast or Left Breast as it applies:
Pain

Right Breast Left Breast
Tenderness

Right Breast Left Breast
Lumps

Right Breast Left Breast
Change in breast size?

Right breast Left Breast
Areas of skin thickening or dimpling

Right Breast Left Breast
Secretions of the nipple

Right Breast Left Breast
Have you had any type of Vaccination in the last 4 weeks?

Left Arm Right Arm No
PATIENT DISCLOSURE:

I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report. By signing below, I certify that I have read and understand the statements above and consent to the examination.
Signature

Clear
Date

Month Day Year
Date
Should be Empty: