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Thermography Intake Form
Thermography Patient Intake
Address Line 1
Address Line 2
District of Columbia
Age and Date of Birth
Primary Care Physician
Any Past Thermography Scans? (please list dates)
Past Scan Results
Your General Health History:
Family Health History:
Any Current / Past Diagnosis:
Skin Lesions or Physical Abnormalities:
How many mammograms have you had in your lifetime?
Check if "Yes"
I've had a close relative with breast cancer
I've been diagnosed with breast cancer
I've been diagnosed with other breast disease
I've had biopsies or other surgeries on breast
I've had cosmetic surgery or implants
I've had a mammogram in past 12 months
I've had a mammogram in past 5 years
I've had abnormal results from breast testing
I've taken contraceptive pills for more than one year duration
I've been diagnosed with cancer of the womb
I've taken any hormone replacements
I get regular annual physicals with my doctor
I perform monthly breast exams on myself
At what age was your first mammogram?
How many births have you had?
Your age at the birth of your first child:
Did your periods start before age 12?
At what age did your periods stop?
Do you smoke? Did you ever? Please explain:
Do you have ANY breast tenderness, lumps, dimpling, change in breast size, areas of thickening, or secretions of the nipple? Please explain in detail:
If you were ever diagnosed with cancer or fibrocystic disease, please explain type, location, treatment, and current state: (please be specific)
Electronic Signature - I understand that Thermography is not a substitute for medical care and that this clinic practices under their Pastoral Medical Association’s (PMA) license.
That’s okay, we’re here to help you on your journey.
How can we help?
How can we help?
Information About Plans & Pricing
Schedule a Case Review
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Pastoral Medical Association
MN Bill of Rights
8519 Eagle Point Blvd, Suite 170,
Lake Elmo, MN 55042