MILFORD HOSPITAL BREAST MRI
SCREENING FORM
Name______________________________Date of Birth__________________
Weight_______
Date of Last Menstrual Period______________________
Day of Cycle______________________ Any chance of pregnancy?________
Do you have or have you had Breast Cancer?
YES
_________________When
____________________Where?
NO
Any other previous surgery on your breasts? ___________________________
Any chemotherapy or radiation therapy? ______________________________
Do you have a family history of Breast Cancer?
________________________________________________________________________
Do you have the BRCA-1 or BRCA-2 gene mutation?
YES
NO
Has anyone in your family tested positive for the BRCA-1
or BRCA-2 gene mutation?
YES
NO
Have you had a recent mammogram? ______________________________
Where? ______________________ Do you have the films? ____________
Any pain and/or lumps in either breast? _______________________RT or LT
Any discharge from the nipples? ____________________________ RT or LT
Please list all surgeries:
Have you ever gotten a piece of metal in your eyes?
Have you ever worked as a machinist/welder?
Do you have a pacemaker or defibrillator?
Do you have a brain aneurysm clip?
Any implanted devices in your body?
Any cardiac stents?
Do you have: ____ DIABETES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
_____KIDNEY DISEASE _____RENAL FAILURE
I ATTEST THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE.
I HAVE READ AND UNDERSTAND THE ENTIRE CONTENTS OF THIS FORM AND HAD
THE OPPORTUNITY TO ASK QUESTIONS REGARDING THIS INFORMATION.
SIGNATURE __________________________________DATE_______________
TECHNOLOGIST SIGNATURE_______________________DATE___________