Your age:_______first name: _______________last name:________________file #:________

Your Age: _____ First Name: _______________Last Name: ____________________Date:____________
Phone: ____________________Cell Phone: ____________________ Date of Birth: ___________________
PHYSICIAN/S: ___________________________________________________________________________
When did your physician or nurse practitioner last examine your breasts? _____________________________
Date and location of prior Mammograms: ____________________________________Results: ____________
Date and location of prior breast MRI: ______________________________________ Results: ____________
Date and location of prior Ultrasound: ______________________________________ Results: ____________
Date and location of prior Thermogram: _____________________________________Results: ____________
Your age when you had your first period: ___________ Age of menopause: ____________
Your age when your first child was born: _______ Currently pregnant? __________ Nursing?___________
Have you ever taken hormones? Y / N Premarin/Prempro/Estrace/Evista/Tamoxifen/Birth Control/etc.?
What type and for how long? _____________________________________ Now taking hormones? Y / N
Are you having regular periods? Y / N Date of last period: _____________________
Have you noticed any change/s in your breast/s?
Has any blood relative had breast cancer?

Please complete the dates for any of the following procedures or problems you have had:

Breast Reconstruction ____/____ ________ I understand that I will be responsible for payment at the time of services rendered. Patient Signature: ___________________________________ Date: ______________ Time: __________ Name ________________________________________________________ Age: __________ Today’s Date: ________________________ Birth Date: ________________________________ Address: _____________________________________________________________________ City: _______________________________________ State: _______ Zip: ________________ Phone Numbers:
Who Referred You to our Practice? _____________________________________

REPORTS ARE SENT TO CLIENTS VIA EMAIL
E-mail Address: ____________________________________________________________
I understand that the risk assessment evaluation report generated from my images are intended for use by
trained health care providers to assist in evaluation, diagnosis and treatment. I further understand that the
report does not provide diagnosis of disease, eliminate the possibly that disease is present and that the
report is not intended for self diagnosis or self evaluation.
Payment is due at time of services rendered.
Patient Signature: ________________________________________ Date: _______________

Optional: I give consent to the anonymous use of my Thermal Images and data for continued
research and development of Thermal Breast Health imaging technology.

Patient Signature: ________________________________________ Date: ________________
Thermal Imaging Protocols and Consent
Please check any protocol items that you cannot or did not follow for the evaluating doctors consideration.  You cannot be sunburned or have a fever at the time of your examination.  Avoid chiropractic care, physical therapy, massage therapy, analgesic creams, balms, magnets or poultice for 24 hours prior to your examination. Discuss with your physician BEFORE
discontinuing any of the above.

 Avoid caffeine and nicotine 4 hours prior to examination.  Avoid stimulating the nipple for prior to your examination.  Avoid shaving your under arms for 24 hours prior to your examination.  Do not wear deodorant, or use creams, lotions, talcum powder or skin products on your upper torso.  Avoid rigorous exercise 4 hours prior to your examination.  Avoid taking a bath or shower in HOT water for at least 4 hours prior to your examination.  Please inform us if you have had radiation treatment within the last 6 months. Thermography of the breasts is a procedure utilizing computerized thermal imaging cameras to visualize and obtain an image of the heat coming from the surface of the skin. The thermographic procedure is performed as an aid to the evaluation of abnormal temperature patterns of the breast which may or may not indicate the presence of a disease process. Thermography is NOT a standalone diagnostic tool. It is an adjunctive tool, which while reliable, should be used by the primary care physician along with other diagnostic tests and analysis so as to arrive at a provisional or more complete diagnosis. No surgical procedure should be based on breast thermal imaging alone. Physical examination, mammography, ultrasound, palpation, MRI, biopsy, blood test, etc. are needed to arrive at a final diagnosis. I understand that I will be disrobed from the waist up to allow the surface of my body to cool to an ambient room temperature. This procedure does not use radiation, compression, and it has no known risks or side effects. The information provided will be made available to my personal physician or others as I so designate for further diagnosis and analysis in the overall evaluation of my breast health. I have been given preparation protocols to insure the most accurate thermographic evaluation of my breasts possible and I agree that I have completed the requirements. I certify that I have complied with the above protocols and preparation instructions and/or that I have noted any protocol(s) I was unable to comply with so that a decision can be made as to whether or not I can have thermographic imaging on the day scheduled. I understand that Thermography is not a standalone screening. Having received satisfactory answers to all questions, I consent to the thermographic examination. Patient’s Signature__________________________________________ Date: ________________ Print Patient’s Name ______________________________________________________________

Source: http://www.centralcoastthermography.com/upload/Patient%20Intake%20Forms%202013%20CCT.pdf