MEDITHERM ID:
REPORT NO:
WMC PATIENT ID:
8 Upper Wimpole Street, London W1G 6LH
tel: 020 7486 2196, fax: 020 3637 2822
email: info@wholisticmedical.co.uk
www.wholisticmedical.co.uk
THERMAL IMAGING - BREAST SCREENING REGISTRATION
PERSONAL DETAILS
First appointment date:
Surname:
Forename:
Title:
Mr
Mrs
Ms
Miss
Other
Date of birth:
Address:
Postcode:
Telephone (H):
(Mobile):
E-mail:
Ethnicity:
Occupation:
Referred by:
All information given in the questionnaire will remain strictly confidential and will only be
divulged to the reporting thermologist and any other practitioner that you specify.
Would you like us to send your report by:
Email in pdf format
Hard copy in the post
A free 10 minute consultation to discuss your report with one of our thermographers or Dr
Daya can be arranged should you wish, or if you prefer your referring Practitioner may
discuss your report with you instead.
What is your preferred form of contact for reminders and messages?
By letter
By email (address:
*By landline
*By mobile
)
*Do you give us permission to leave a full message on this number (stating the clinic name
and a brief message on why we are calling you)?
Yes
No
We sometimes use test results from our patients in our research programme and when we
do, this is in a completely anonymous way. It helps us make treatment advances in the
work we are doing. Do you object to the anonymous use of your tests results for research
purposes?
No, I do not object
Yes, I do object
Signed:
Date:
OFFICE USE ONLY: Aftercare / Consultation notes
DITI NP 042012
1
BREAST THERMOGRAPHY CONFIDENTIAL QUESTIONNAIRE
YES
NO
1. Do you have any close relative who has had breast cancer?
2. Have you ever been diagnosed with breast cancer?
3. Have you ever been diagnosed with any other breast disease (fibrocystic)?
4. Have you had any biopsies or surgeries to your breasts?
5. Have you had any breast cosmetic surgery or implants?
6. Have you had a mammogram in the past 12 months?
7. Have you had a mammogram in the past 5 years?
8. Have you had abnormal results from any breast testing?
9. Have you ever taken a contraceptive pill for more than 1 year?
10. Have you suffered with cancer of the womb?
11. Have you ever had hormone replacement therapy?
12. Do you have an annual physical examination by a doctor?
13. Do you perform a monthly breast self exam?
14. How many mammograms have you had in total?
15. What was your age when you had your first mammogram?
16. How many births have you had?
17. Did you breast feed?
Yes
Your age at birth of first child:
No
If so, approximately how long for?
18. Did your periods start before the age of 12?
Or finish after the age of 50?
19. Do you smoke?
Yes
Never
Yes
Yes
No
No
Not in last 12 months
20. Have you recently had any of these breast symptoms:
Not in last 5 years
Right breast
Left breast
Pain
Tenderness
Lumps
Change in breast size
Areas of skin thickening or dimpling
Secretions of the nipple
EXTENDED BREAST QUESTIONNAIRE
Diagnosed with breast cancer:
When diagnosed:
Cancer type:
No
Month/Year
Metastatic
Where (left breast):
Yes
Local
Lymph node involvement
Where (right breast):
Upper Outer
Upper Outer
Upper Inner
Upper Inner
Lower Outer
Lower Outer
Lower Inner
Lower Inner
Nipple
Nipple
Treatment:
Surgery
DITI NP 042012
Chemo
Radiation
Other
None
Please mark X to show
location
Right Breast
Left Breast
2
Diagnosed with other breast disease:
When diagnosed:
Disease type:
Month/Year
Fibrocystic
Cystic
Mastitis
Abscess
(please report other types of disease in the history
Other
)
Breast biopsies or surgery:
When diagnosed:
Month/Year
Where (left breast):
Upper Outer
Upper Inner
Lower Outer
Lower Inner
Nipple
Lower Outer
Lower Inner
Nipple
Where (right breast):
Upper Outer
Upper Inner
GENERAL HEALTH QUESTIONS
1. Please state below any diagnosed health conditions you have:
2. Please list any current symptoms you are experiencing:
3. Please state below what prescribed medication and/or nutritional supplements you are
currently taking:
4. Prescribed Medicines:
5. Nutritional Supplements:
6. Are you vegetarian or vegan?
Yes
If yes how long for?
No
Do you eat red meat?
Yes
No
7. How many silver fillings do you currently have in your mouth?
None
1-2
4-6
A mouthful
Have you had any silver/amalgam fillings replaced?
Yes
No
If so when?
8. Do you use products containing aluminium such as:
Aluminium foil in cooking?
Aluminium pans?
Anti perspirants or deodorants containing aluminium?
Can you see the aluminium element at the bottom of your kettle?
9. Do you use hair dye?
Yes
No
Do you dry skin brush?
Yes
How often?
No
10. If you smoke cigarettes, etc. how many do you smoke per day?
11. If you drink alcohol state daily consumption and type:
12. How much water do you drink per day?
13. How often do you eat foods containing the following:
Dairy
daily
weekly
monthly
rarely
Caffeine
daily
weekly
monthly
rarely
Wheat
daily
weekly
monthly
rarely
Sugar
daily
weekly
monthly
rarely
DITI NP 042012
3
13. Do you drink tea and/or coffee? If YES please complete questions below:
Cups of tea per day:
Cups of coffee per day:
Do you take sugar with your beverage?
yes
no
Do you take artificial sweeteners with your beverage?
14. Do you sleep well?
15. Do you exercise?
yes
yes
Type of exercise:
yes
no
no How many hours sleep do you get per night?
no
How often?
16. If you are still having menstrual cycles, are your periods regular?
yes
no
When was your last menstrual period?
Where in your cycle are you right now?
17. If you are post menopausal, when did you start the menopause?
18. Are you currently taking HRT or the contraceptive pill?
19. What is your weight?
Do you consider your weight to be:
Normal
20. Do you consider yourself to be under stress?
yes
Under
Over
no
What type of stress?
Questions relating to ElectroSmog
1. How long do you spend daily on your mobile phone?
2. Where on your body do you place your mobile phone?
3. When using your mobile phone do you use ear piece
or phone to ears
?
4. Do you sleep with your mobile phone close to you?
5. Are you aware of any phone masts stations near to your home?
6. How long do you spend daily on the computer?
7. How often do you take flights abroad?
8. Short Haul Flights
9. Long Haul Flights
10. Do you have/use a digital cordless phone at home and/or at work?
11. Do you have wifi at home / work?
12. Do you switch the wifi off at night?
PATIENT DISCLOSURE
I understand that the report generated from my images is intended for use by trained health care providers to
assist in evaluation, diagnosis and treatment. I further understand that the report is not intended to be used by
individuals for self-evaluation or self-diagnosis. I understand that the report will not tell me whether I have any
illness, disease, or other condition but will be an analysis of the Images with respect only to the thermographic
findings discussed in the report.
I would like to be shown how to do a self-breast examination
yes
no
I would like a copy of my report to be sent to my referring practitioner.
yes
no
Finally, I understand that it is my own responsibility as the patient to choose whether to accept any treatment
or test options professionally offered.
yes
no
By signing below, I certify that I have read and understand the statements above and consent to the
examination.
Signature:
DITI NP 042012
Today’s date:
4
A Positive Outlook
Please remember that whilst Thermal Imaging is an excellent screening tool for early
detection of underlying metabolic and physiological processes, it does not and cannot offer
a diagnosis. Only a tissue biopsy can give a definitive diagnosis.
Early detection of heat abnormalities allows for proactive and holistic healthcare
approaches to help reverse a potentially serious disease process.
We therefore encourage you to focus on these positive, proactive aspects. A snapshot into
the invisible energy world, Thermal Imaging provides us with images that help motivate us
to bring about basic lifestyle changes to reduce the toxic load on our body and encourage
the healing process. These changes can be demonstrated using comparative analysis with
Thermal Imaging over a period of time
THERMAL IMAGING - IMPORTANT INFORMATION FOR PATIENTS
Please read this prior to your breast scan
About Thermal Imaging
Thermal Imaging is a safe, non invasive screening method which effectively screens for
changes in the physiology of breast tissue over time. It provides useful information about
inflammation, lymphatic, hormonal and vascular abnormality in the body.
This information leads to the justification of further tests, observations or maintenance. It
provides the opportunity for early intervention and preventative treatment.Thermal
Imaging uses an infrared camera with a sophisticated heat sensor to detect and distinguish
various temperatures found in the breast.
Preparation information: Getting the best scan picture
To ensure the best quality thermal scan, it is important to avoid anything that may heat
the body or irritate the skin surface on the day of the scan. Please read the guidelines
below and AVOID the following on the day of your scan:
ACTIVITY:
Smoking for 3 hours prior to the scan
Hot showers
Sunbathing
Shaving or waxing your underarms
DIET:
Using deodorant, antiperspirant, creams, lotions or hormone creams on the day of the
scan.
Physical therapy, such as massage, physiotherapy for 24 hours before the scan,
unless otherwise advised by a doctor or practitioner
Carrying heavy bags on your shoulder or have straps across the breast region under
the arms. Also avoid scratching or rubbing the skin surface, especially of the upper
body.
Hot drinks and food for 3 hours prior to screening
Alcohol
Caffeine
MEDICINE:
Where possible, do not take anti-inflammatory or anti-histamine medication.
However, a thermography examination should not stop you from taking your normal
medication. Please bring a list of your medication with you to the examination.
Please wait 3 – 4 months after radiation or surgery, including biopsies to have a
thermal scan.
DITI NP 042012
5
THE PROCEDURE
Please note that all our thermographers are female.
Prior to the examination
You will be asked to complete a questionnaire. Please bring this completed questionnaire
with you. It is advisable to allow plenty of time for your travel to Harley Street so that
you have a few minutes before your scan to relax and allow your body temperature to cool
down. You are entitled to request a chaperone to be present at your Thermal Imaging
session. If you wish to bring your partner, friend or relative along, please do so.
What does the procedure involve?
You will be directed to a private room where a female thermographer will confirm details of
your case history with you. You will then be shown to a screened scanning area and will be
asked to remove your upper body clothing, jewellery and secure hair away from your neck.
Surgical gowns and hair clasps / nets are available for your comfort should you wish. The
thermographer will discuss the images to be taken.
Once your body temperature has stabilised after a few minutes, the images will be taken.
For the breast scans, 6 images are taken and you will be asked to clasp your hands behind
your head for a few seconds while each scan takes place.
At the end of the session, you will have the opportunity to look at the pictures briefly.
We allow 1 hour for the first scan and subsequent scans are just 30 minutes.
Report
Your scan report will normally be available during the week following your scan and it can
be sent to you by email in a pdf format or by post. If you need your scan results more
urgently, please discuss this with the Thermographer at the time of your scan. Additional
reports can be sent to your referring practitioner, on request.
Aftercare and Advice
If you have any questions about your report or would like some advice on what options are
available to you, please call the office and ask to speak to the Thermographer. Please note
that the Thermographer is not qualified to interpret your report. A telephone discussion
with Dr Daya may also be possible.
Please note that the DITI reports should not be used for self diagnosis. It is important to
discuss the results with a qualified practitioner.
Having a thermogram does not replace the possible need for an anatomical test such as
mammograms, ultrasounds and MRI’s at some time. The use of both methods of testing
gives the best possible opportunity for early detection.
If you would like any more information, please visit our website
www.wholisticmedical.co.uk or feel free to call the office on 020 7486 21 96 with any other
questions.
We look forward to meeting you soon.
DITI NP 042012
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