Living Springs Natural Health (LSNH) & Living Springs Health & Wellness (LSHW), PLLC are members under the:

TURTLE ISLAND PROVIDER NETWORK Licensed & Registered by: Tribal Health Programs & Clinics

A Private Tribal Membership Facility NOT OPEN TO THE PUBLIC

THERMOGRAPHY - BREAST QUESTIONNAIRE

Name: Type Name: Last, First Middle Date: Select Today’s Date
Date of Birth: Select D.O.B. Age: Age Occupation: Occupation
Home Address: Enter Street Address City: Enter City State: Enter State Zip: Enter Zip
Email Address: Enter Email Address
Home Phone: Enter Home Phone # Cell Phone: Enter Cell Phone # Work: Enter Work Phone #
In Case of Emergency Contact: Emergency Contact Relationship: Relationship Phone: Enter Phone #
How did you hear about Us: Enter Text
Please list all the providers you are seeing and/or referring physician: List Providers
Is there a specific reason or concern for this exam? Enter Text

1. Have you recently had any of these breast symptoms?	Yes No

(mark LT or RT if “yes”)	☐	☐

LT	RT

Pain/Tenderness	☐	☐

Lumps	☐	☐

Change in breast size	☐	☐

Areas of skin changes thickening or dimpling	☐	☐

Excretions or changes of the nipple	☐	☐

2. Are any of the above symptoms cycle related?	☐	☐

3. Are you still having your periods?	☐	☐

If yes, date of last period: Select Date

4. Have you had a surgical hysterectomy?	☐	☐

If yes, date Enter Month/Year:	☐ Complete	☐ Partial

Reason for hysterectomy?

☐ Excess bleeding ☐ Endometriosis ☐ Fibroid cysts ☐ Cancer ☐ Other

5. Has anyone in your family ever been treated for breast cancer?	☐	☐

If yes, note age and survival ☐ Mother	☐ Grandmother ☐ Sister ☐ Daughter

Age diagnosed: Enter Age	Result of Treatment: Enter Text

Yes No

6. Have you ever been diagnosed with breast cancer?	☐	☐

If yes, date Enter Month/Year:

Cancer type	:	☐ Local	☐ Metastatic	☐ Lymph node involvement

Left breast	☐ Inner	☐ Outer	☐ Nipple

Right breast	☐ Inner	☐ Outer	☐ Nipple

Treatment	☐ Surgery	☐ Chemo	☐ Radiation	☐ None

7. Have you ever been diagnosed with any other breast disease?	☐	☐

If yes:	☐ Cysts/fibrocystic	☐ Fibro Adenoma	☐ Mastitis/inflammatory breast disease

8. Have you had any cosmetic breast surgery or implants?	☐	☐

If yes, date: Enter Month/Year	☐ Silicone	☐ Saline

Experience:	☐ Problems	☐ No problems

9. Have you ever had any biopsies or any other surgeries to your breasts?	☐ ☐

If yes, date: Enter Month/Year

Left breast	☐ Inner	☐ Outer	☐ Nipple

Right breast	☐ Inner	☐ Outer	☐ Nipple

Results	☐ Negative	☐ Positive	☐ Calcifications

10. Have you ever taken contraceptive pills for more than one year?	☐	☐

If yes:	☐ Currently	☐ Less than 5 years	☐ More than 5 years

11. Have you had pharmaceutical hormone replacement therapy (HRT)?	☐	☐

If yes:	☐ Currently	☐ Less than 5 years	☐ More than 5 years

12. Do you have an annual physical examination by a doctor?	☐	☐

13. Do you perform a monthly breast self exam?	☐	☐

14. Have you ever smoked?	☐	☐

15. Have you ever been diagnosed with diabetes?	☐	☐

16. Total # of mammograms: Enter #

17. Date of last mammogram: Enter Month/Year	Were you re-called?	☐	☐

18. Your age at your first mammogram? Enter Age

19. Number of full term pregnancies? Enter #

20. Have you had breast ultrasound?	☐	☐

If yes, Date: Enter Month/Year ☐ Left	☐ Right	Results: ☐ Negative	☐ Positive

21. Have you had breast MRI?	☐	☐

If yes, Date: Enter Month/Year ☐ Left ☐ Right Results: ☐ Negative ☐ Positive

Procedure: You will be imaged with a state of the art infrared imaging camera in comfortable and controlled surroundings. Your thermal imaging baseline reports will provide information about current and future conditions only and does not diagnose breast disease. Thermal imaging should be correlated with other medical investigative methods to better direct definitive testing for diagnosis and treatment. It does not replace any other breast examination.

Patient Disclosure: I understand that the report generated from my images is intended for use by a trained health care provider to assist in evaluation and treatment. I further understand that the report is not intended to be used by myself for self-evaluation or self-diagnosis. I understand that the report will not tell me whether, I have any illness, diseases, or other conditions, 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 statement above and consent to the examination.

*** Please Note: We do not file with insurance at this office & will not provide codes. The alternative therapies/suggestions we provide are not intended to diagnose, treat, cure or prevent any disease ***

☐ I understand, agree & provide my consent that the submission of this form electronically requires the use of a digital signature. By signing, I agree that my digital signature on this form has the same legal affect as my manual signature (in accordance with the ESIGN Act).

Date: Click to Select a Date.

E-SIGN Your Name Here
Patient Signature

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