Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Have you had thermography before? *YesNoAre you currently undergoing Electro-Lymphatic Therapy? *YesNoName *FirstLastEmail *Address *Phone Number *Age *Mark Each Box if 'Yes'Do you have any close relative who has had breast cancer?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?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 *Yes, CurrentlyNo, but used toNo, only smoked a few timesNo, never smoked Check any RECENT symptoms that apply to your RIGHT breast: PainPainTendernessLumpsChange in breast sizeAreas of skin thickening or dimplingSecretions of the nippleCheck any RECENT symptoms that apply to your LEFT breast:PainTendernessLumpsChange in breast sizeAreas of skin thickening or dimplingSecretions of the nippleCurrent SymptomsCurrent TreatmentsCurrent MedicationsPrevious Surgeries including date Dental History (e.g. root canals, periodontal disease, crowns) General Medical History * Significant Family History *Skin Lesions or Physical Abnormalities *Breast cancer type (if applicable)MetasticLocalLymph node involvementWhen were you diagnosed? (month/year)Where was the cancer in the RIGHT breast? (if applicable) Upper OuterUpper InnerLower OuterLower InnerNippleWhere was the cancer in the LEFT breast? (if applicable)Upper OuterUpper InnerLower OuterLower InnerNipple Address when Current What treatment have you had?SurgeryChemoRadiationOtherNone What type of OTHER breast disease have you been diagnosed with? (if applicable) FibrocysticCysticMastitisAbscessOtherWhere in your RIGHT breast have you had a biopsy? (if applicable) Upper OuterUpper InnerLower OuterLower InnerNippleWhere in your LEFT breast have you had a biopsy? (if applicable) Upper OuterUpper InnerLower OuterLower InnerNippleSubmit Notice: JavaScript is required for this content.
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