Client Intake Form

Do you examine your breasts?

Visually Physically I do not examine my breasts

Do you have Fibrocystic breasts?

Yes No

Stress Level (0-5)

Is this your first Thermogram?

Yes No

When was your last physical exam in a healthcare providers office?

Do you have Dense breasts?

Yes No

When was your last Mammogram?

Have you had a Breast Ultrasound?

Yes No

Have you had a Breast MRI?

Yes No

Please provide copies of your latest reports from the screenings above. You can upload them here or bring them to your appointment.

Age you had your first period?

Have you had a Hysterectomy?

Yes No

Day one of your last cycle

Are your cycles regular?

Are you on birth control?

Yes No

Are you taking hormones?

Yes No

Bioidentical?

Yes No

If any of the answers to the above questions is yes, please indicate how long?

If you are not currently on Birth Control, or Hormones, what is your history of Birth Control or Hormone Replacement?

In Vitro Fertilization?

How many pregnancies?

# Terminated pregnancies

Have you noticed any change(s) in your breasts? Check below all that apply:

Appearance

Right Left

Nipple Fluid

Right Left

Inverted Nipple

Right Left

Please describe from the diagram below where you have anything noteworthy (past or present), such as locations of cysts or cyst aspirations, biopsies, surgeries, skin problems, infections, calcifications, etc.

Please indicate below the procedures you have had and dates of these procedures:

Breast Reductions

Right Left

Breast Implants Silicone or Saline

Silicone Right Silicone Left Saline Right Saline Left

Breast Infection

Right Left

Radiation Treatment (Chest/Neck)

Right Left

Core Needle Biopsy

Right Left

Surgical Biopsy

Right Left

Lumpectomy

Right Left

Radiation Therapy

Right Left

Cyst Aspirated

Right Left

Mastectomy

Right Left

Injury to Breast

Right Left

COVID Vaccine within the past 2 months?

Yes No

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