Womens_Health_Check_Questionnaire

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

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

YesNo
Ever been diagnosed with breast cancer?

LeftRightYesNo
Date

MonthDayYear
Date
Diagnosed with any other breast disease? (Fibrocystic, Mastitis, Cystic, Abscess)

YesNo
Any biopsy or surgery to your breasts?

LeftRightYesNo
Date

MonthDayYear
Date
Cosmetic surgery to breasts? (Implants, reduction, lift)

LeftRightYesNo
Date

MonthDayYear
Date
Do you have dense breast tissue?

YesNo
Have you had a mammogram in the past 12 months?

YesNo
Have you had more than 30 mammograms in your lifetime?

YesNo
Mammogram in the past 5 years?

YesNo
Date

MonthDayYear
Date
Any abnormal results from any breast testing?

YesNo
Ever taken a contraceptive pill for more than 4 years?

YesNo
How Long?
Ever diagnosed with ovarian, uterine or cervical cancer?

YesNo
Ever taken hormone replacement therapy? (Pharmaceutical or bio-identical)

YesNo
Do you have an annual physical breast examination by adoctor?

YesNo
Do you perform a monthly breast self-exam?

YesNo
Did your periods start before the age of 12?

YesNo
Did your periods end after the age of 50?

YesNo
Are you still having a menstrual cycle?

YesNo
Have you ever given birth to a child?

YesNo
Have you ever smoked for more than 5 years?

YesNo
Is your menstrual cycle irregular?

YesNo
Do you experience cramping during your menstrual cycle?

YesNo
Do you have heavy bleeding with your menstrual cycle?

YesNo
Do you have breast tenderness that comes and goes?

YesNo
Do you have any breast lumps that come and go?

YesNo
Do you have low libido? (low sex drive?)

YesNo
Do you have hot flashes?

YesNo
Have you ever been diagnosed with endometriosis?

YesNo
Have you ever been diagnoses with PCOS (poly cystic ovarian syndrome)?

YesNo
Have you ever been treated for infertility?

YesNo
Do you have any swelling in the neck or trouble swallowing?

YesNo
Any thyroid disorder? (hypothyroid/ hyperthyroid/ Hashimoto’s/ Grave’s disease)

YesNo
Do you regularly experience fatigue?

YesNo
Have you experienced recent hair loss?

YesNo
Mark Right Breast or Left Breast as it applies:
Pain

Right BreastLeft Breast
Tenderness

Right BreastLeft Breast
Lumps

Right BreastLeft Breast
Change in breast size?

Right breastLeft Breast
Areas of skin thickening or dimpling

Right BreastLeft Breast
Secretions of the nipple

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

Left ArmRight ArmNo
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

MonthDayYear
Date
Should be Empty: