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Female Thermography Form.

Please complete the form to the fullest, and to the best of your knowledge.

Thermography Medical History Form

Birthday

Breast Questionnaire:

Do you have any close relative who has had breast cancer?
Have you ever been diagnosed with breast cancer?
Have you ever been diagnosed withany other breast disease?
Have you ever had any biopsies or surgeries to your breasts?
Have you ever 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 any abnormal results from any breast testing?
Have you ever taken a contreceptive pill for more than 1 year?
Have you ever suffered from Uterine or Ovarian cancer?
Have you ever had hormone replacement therapy?
Have you had an annual physical breast examination by a doctor?
Do you perform a monthly breast self-exam?
Did your periods start before the age 12?
Did your periods end after the age 50?
Have you had a vaccinnation in the past 4 weeks?
How many mammograms have you had?
How many children have you given birth to?
Do you smoke, or have you ever smoked?

Have you had any of the following breast related symptoms?

Pain?
Tenderness?
Lumps?
Change in breast size?
Areas of skin thickening or dimpling?
Secretions from the nipple?
DIagnosed with a breast disease?
Yes
No
Disease type?

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