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Microsoft word - thermography intake form.doc

Thermography Clinic Inc.
BREAST HEALTH HISTORY
Name: _________________________________________ Age: _____ Date of Birth: _______________________ Address: _______________________________ City: ______________________Postal Code _________________ Home Tel: ____________________ Work Tel: _____________________ E-mail ___________________________ Occupation: __________________________________________________________________________________ Marital Status: S M D W SEP. Number of Children: _____ Referred by: _______________________________ -------------------------------------------------------------------------------------------------------------------------------- Do you have a family history of breast cancer? r Self r Mother r Maternal Grandmother r Sister r Daughter r None Do you have any diagnosed breast conditions? r None r Fibrocystic r Cystic r Other ______________________________________ Have you previously had a thermogram? Date of most recent _______________________ Was it: r Normal r Abnormal r Suspicious r Being watched Have you had a mammogram? Date of most recent _______________________________ Was it: r Normal r Abnormal r Suspicious r Being watched Have you had a breast ultrasound? Date of most recent_____________________________ Was it: r Normal r Abnormal r Suspicious r Being watched Have you had a breast exam by a doctor? Date of most recent _______________________ Was it: r Normal r Lump Found Any breast biopsies? When and what type (i.e. needle, core)? ___________________________ Any breast surgeries? When and what was done? ____________________ Have you had a mastectomy? When? _____________________________ Have you had radiation? When was it last performed? ________________ Have your had your ovaries removed? At what age? _______________________________ Do you have children. At what age was your first full term pregnancy? _______________ Did you nurse for at least three months? How long ________________________________ Are you currently taking birth control pills? At what age did you start? _________________ for how many years? ________________ Are you in menopause? At what age did it begin? _________________________________ Have you ever taken synthetic hormone replacement (ex. Premarin, Provera)? Are you currently using natural progesterone cream? Applied to r Breasts only r Rotating body areas Are you currently using herbals, homeopathic medicines, or supplements to stimulate or simulate estrogen? Explain ___________________________________________________ Do you feel that you are overweight? How many pounds overweight? _________________ Are you experiencing any of the following with your breasts?
A lump. Date found: _________________ by r Self r Doctor It is: r Hard r Soft r Mobile r Tender Pain It is r Dull r Sharp r Burning r Stinging r Tender r Changes with my cycle Skin changes (r Color r Texture r Over the lump) It is r Bloody r Milky r Through one duct r through multiple ducts Nipple changes r R r L Breast Change in: r Color r Texture Other __________________________________________________________________ Place an [O] on the diagram in the exact area of the lump, finding on your mammogram, or area being
watched, and an [X] in the area of pain, tenderness, thickening, or skin changes.

Please note any other concerns/issues you may have: __________________________________________ General Health Information
Do you have any medical complaints or conditions? Please explain ___________________
_________________________________________________________________________


r Y r N
Are you currently taking any medications? Please list ______________________________ _________________________________________________________________________
Please circle all of the following conditions which you have had:

Other ________________________________________________________________________________
r Y r N
Are there any of the preceding conditions after which you have never been totally well again, or which have been more severe than usual? Explain? ________________________
r Y r N
Have you had any operations? Which __________________________________________ Have you lost any weight recently? How many pounds? ____________________________ Do you exercise? How often? ________________________________________________ Have you had any major injuries? Explain _______________________________________ Are you taking any of the following substances? How much?
Tobacco: _____________________
Alcohol: ___________________________________ “Recreational Drugs” _________________________ Have any of the following ailments affected your relatives? Alcoholism
FAMILY HISTORY
Age if Alive
Age at Death
AILMENTS
Mother: Father: Brothers: Sisters: Children: Maternal Grandmother: Maternal Grandfather: Paternal Grandmother: Paternal Grandfather:

Source: http://www.thermographyclinic.com/forms/Breast_Health_History_Form.pdf

Doi:10.1016/j.fertnstert.2006.08.023

Use of clomiphene citrate in women The Practice Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, AlabamaOvulatory dysfunction is one of the most common causes ofover consecutive cycles of treatment, but there is no evi-reproductive failure in sub-fertile and infertile couples. In thedence of any important clinical conseque

Microsoft word - student handbook 1-13.docx

Ethel Lund Village Health Occupations Program Student Handbook Sponsored by SouthEast Alaska Regional Health Consortium “Your Partner in Health” Table of Contents General Guidelines/Suggestions for Students Ethel Lund Village Health Occupations Program Thank you for choosing to participate in the Ethel Lund Village Health Occupations Pr

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