CAROLINA THERMASCAN, LLC
BREAST HEALTH QUESTIONNAIRE
First Name ______________________ Middle Initial_____ Last Name _______________________
Date of Birth ____/___/______ Age ______
Address ________________________________________________________________________
City ___________________________________State_______________ Zip________________
Home Phone# _______________ Work Phone#_________________ Cell Phone#_____________
e-mail: __________________________________________________________________________
Please tell us how you heard about Carolina Thermascan__________________________________
Patient of: (circle one)
Carolina Center for
Integrative Medicine
Vaughan
Integrative Medicine
Insight Family
Health Center
Other: _______________
____________________
Were you referred by a health care practitioner? Yes____ No ____ If so, we will send a copy of your scan
and report to that practitioner. Please provide name and address:
__________________________________________________________________________________________
__________________________________________________________________________________________
CURRENT MEDICATIONS AND SUPPLEMENTS:
Medications: _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Supplements: ______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
FAMILY HISTORY OF BREAST CANCER (check all that apply)
Self ___age____
Mother_____Sister_____Daughter_____ Maternal Grandmother____Maternal Aunt___
Maternal cousin___Paternal Grandmother____Paternal aunt____Paternal cousin____
4505 Fair Meadow Lane  Suite 111  Raleigh, NC 27607
Telephone: 919-781-6999  Fax: 919-571-8968
Revised 11-13
NOTES:
Indicate by letter on the diagram the region of the breasts if affected by the following:
A Mass
B Thickening
F Area of Pain G Burning
C Discharge D Nipple Change
H Tender
I Dull Ache
E Skin Change
J Sharp Pain
PLEASE ANSWER THE FOLLOWING QUESTIONS
Have you ever had a biopsy? Yes ____ No____ Location: _______ Date:_______ Outcome:_______
Any history of breast cancer? Yes ____ No ____ Location: ______ Date:_______ Outcome:_______
Lumpectomy:
Yes ______ No _______ R________ L ________ Year of Surgery_________
Mastectomy:
Yes ______ No _______ R________ L ________ Year of Surgery_________
Breast Reconstruction:
Yes ______ No________R________ L ________ Year of Surgery_________
Radiation to the Breast:
Yes ______ No_______ R________ L ________ Year of Treatment_______
Chemotherapy:
Yes ______ No_______ R________ L ________ Year of Treatment_______
Breast Augmentation:
Yes ______ No________R________ L ________ Year of Surgery ________
Any palpable mass now?
Yes ______ No________R________ L ________
Any discharge, inversion or change in nipples? Yes ______ No________R________ L ________
KEY DATES:
Last mammography exam: ____________ Normal _______ Abnormal________ Suspicious________
Approximate dates previous mammograms or interval between: _______________________________
___________________________________________________________________________________
Last breast ultrasound:________ Location _______Normal _______ Abnormal________ Suspicious_______
Last MRI:
____________ Normal _______ Abnormal________ Suspicious________
Last thermal image:
____________ Normal _______ Abnormal________ Suspicious________
The information supplied is, to my knowledge, true and complete.
Please print name: _______________________________________________________________
Client signature: _____________________________________________________
Date: ____________
4505 Fair Meadow Lane  Suite 111  Raleigh, NC 27607
Telephone: 919-781-6999  Fax: 919-571-8968
Revised 11-13