Female Thermography Forms Fields marked with an * are required Have you had thermography before? * Yes No Are you currently undergoing Electro-Lymphatic Therapy? * Yes No First Name * Last Name * Address * City * US States * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * Phone * Email * Date of Birth * Divider Do you have any close relative who has had breast cancer? If yes, enter relationship and state if on maternal or paternal side (e.g. maternal grandmother) Have you ever been diagnosed with breast cancer? Have you ever been diagnosed with any other breast disease (fibrocystic)? Have you ever had any biopsies or surgeries to your breasts? Have you had any breast cosmetic surgery or implants? If yes, was it saline or silicone, and in what year? Have you had a mammogram in the past 12 months? Have you had a mammogram in the past 5 years? Have you had abnormal results from any breast testing? Have you ever taken a contraceptive pill for more than 1 year? Have you ever been diagnosed with cancer of the womb? Have you had pharmaceutical or bio-identical hormone replacement therapy? Do you have an annual physical examination by a doctor? Do you perform a monthly breast self exam? Did your periods start before the age of 12? Did your periods end after the age of 50? How many mammograms have you had in total? (estimate) How old were you when you had your first mammogram? How many births have you had? How old were you when you gave birth the first time? In what year was your last mammogram? Do you smoke? * Please select one... Yes Never Not in last twelve months Not in last five years Check any RECENT symptoms that apply to your RIGHT breast: Pain Tenderness Lumps Change in breast size Areas of skin thickening or dimpling Secretions of the nipple Check any RECENT symptoms that apply to your LEFT breast: Pain Tenderness Lumps Change in breast size Areas of skin thickening or dimpling Secretions of the nipple Current Symptoms Current Treatments Current Medications Previous Surgeries (Include Dates) Dental History (e.g. root canals, periodontal disease, crowns) General Medical History Skin Lesions or Physical Abnormalities Significant Family History Divider Breast cancer type (if applicable) Metastic Local Lymph node involvement When were you diagnosed? (month/year) Where was the cancer in the RIGHT breast? (if applicable) Upper Outer Upper Inner Lower Outer Lower Inner Nipple Where was the cancer in the LEFT breast? (if applicable) Upper Outer Upper Inner Lower Outer Lower Inner Nipple What treatment have you had? Surgery Chemo Radiation Other None Divider Copy What type of OTHER breast disease have you been diagnosed with? (if applicable) Fibrocystic Cystic Mastitis Abscess Other Divider Copy Copy Where in your RIGHT breast have you had a biopsy? (if applicable) Upper Outer Upper Inner Lower Outer Lower Inner Nipple Where in your LEFT breast have you had a biopsy? (if applicable) Upper Outer Upper Inner Lower Outer Lower Inner Nipple If you are a human seeing this field, please leave it empty.