Men's Full Body

Men's Full Body

Confidential Questionnaire
Name*

FirstLast
Birth Date*

MonthDayYear
Today's Date*

MonthDayYear
Address*
City*
State*
Zip*
Phone (Home)*

Area CodePhone Number
Phone (Cellular)

Area CodePhone Number
Phone (Work)

Area CodePhone Number
Email*
Referring Physician

FirstLast
If you have copies of related test results (e.g. mammograms, ultrasounds, biopsies) please upload them here.

Browse Files

Cancelof
All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting thermographer and any other practitioner that you specify.
Head & Neck
1. Do you suffer with headaches?*

YesNo
If Yes

Once a month or lessMore than once a month
2. Do you have known allergies?*

YesNo
If Yes:

FoodEnvironment
Do you wear contact lenses?*

yesno
3. Do you have TMJ or does your jaw click?*

YesNo
4. Do you currently have a cold?*

YesNo
5. Are you being treated for a thyroid disorder?*

YesNo
Type
6. Do you have neck pain?*

YesNo
7. Do you have upper back pain?*

YesNo
8. Do you have a known history of carotid artery disease?*

YesNo
9. Do you have a family history of stroke?*

YesNo
10. Do you currently suffer with sinus problems?*

YesNo
11. Do you have history of dental problems?*

YesNo
If Yes:

Root CanalsGum DiseaseImplantsNon-replaced extractionsDentures
12. Have you had dental cleaning in the past 7 days?*

YesNo
Do you have any special concerns or are there any details related to the information above?
Chest, Heart & Lungs

1. Have you been diagnosed with:*

	Yes	No
Heart disease?
Lung disease?
Upper spine disorders?

2. Do you suffer with upper back pain?*

YesNo
3. Do you suffer with chest pain?*

YesNo

4. Have you ever had surgery to your:*

	Yes	No
Heart?
Lungs?
Mid to upper back?

5. Do you have asthma or shortness of breath?*

YesNo
6. Do you currently smoke?*

YesNo
7. Have you smoked in the past 5 years?*

YesNo
Do you have any special concerns or are there any details related to the information above?
Abdomen & Lower Back
1. Do you suffer with acid reflux or otherdigestive problems?*

YesNo

2. Do you suffer pain in the:*

	Yes	No
Stomach?
Below R Breast?
Below L Breast?
Abdomen?
Lower Back?
Pelvic Region?

3. Have you had surgery or disease in the:*

	Yes	No
Stomach?
Spleen(Upper Left) ?
Liver(Upper Right) ?
Kidneys ?
Intestines ?
Abdomen ?
Lower Back?
Pelvic Region?

4. Have you consumed alcohol in the last 24 hours?*

YesNo
Do you have any special concerns or are there any details related to the information above?
Legs & Feet

Check only if "Yes"

1. Do you suffer pain in the:

	LT	RT	Both	None
Legs?
Sciatica?
Buttocks/Hip?
Knees?
Ankles?
Feet?

2. Have you had Surgery to:

	LT	RT	Both	None
Legs?
Sciatica?
Buttocks/Hip?
Knees?
Ankles?
Feet?

Do you have any special concerns or are there any details related to the information above?
Arms & Hands

Check only if "Yes"

1. Do you suffer with pain in the:

	LT	RT	Both	None
Shoulder?
Elbow?
Arm?
Hands?

2. Have you had surgery to:

	LT	RT	Both	None
Shoulder?
Elbow?
Arm?
Hands?

Areas of Pain
Do you have any special concerns or are there any details related to the information above?
Hips

1. Do you experience any of these hip related symptoms?:

	Left hip	Right Hip
Pain when standing
Pain when walking
Pain in lower back
Pain in groin
Pain in knees

2. Have you ever been diagnosed with:

	Yes	No
Bursitis
Arthritis
Tendonitis
Sciatica
Hip fracture

3. Have you been treated for hip pain?:

	Yes	No
Orthopedic
Chiropractic
Physical Therapy
Surgery
Injection

Do you have any special concerns or are there any details related to the information above?
Please Check boxes that you acknowledge and understand the General imaging instructions*
Please check boxes that you acknowledge and understand Day of imaging Instructions*
Signature

Clear
Date*

MonthDayYear
Date
Client Disclosure
Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health.

Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures.

Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor.

A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately.

Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised.

Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

By signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.
Name*

First NameLast Name
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Authorization to Use or Disclose Protected Health Information
Patient Name*
Address*
City*
State*
Zip*
Date of Birth:*

MonthDayYear
Date
Date of Request:*

MonthDayYear
Date
As required by the Privacy Regulations, Lisa’s Thermography and Wellness may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

Thermography Medical Clinic, LLC and
Doctor's Name
Doctor's Phone Number

Area CodePhone Number
Doctors Fax Number

Area CodePhone Number
Doctor's Email
example@example.com
Town your doctor practices in:
State your doctor practices in:
Patient Health Information authorized to be disclosed: Thermal Images, health history, and commentary

For the specific purpose of Interpretation of said images and related commentary
Effective dates for this authorization:*

MonthDayYear
Date
I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.

I understand I have the right to:

Revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization.

Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.

Inspect a copy of Patient Health Information being used or disclosed under federal law.

Refuse to sign this authorization.

Receive a copy of this authorization.

Restrict what is disclosed with this authorization.

I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.
Signature or Patient or Patient’s Authorized Representative*

Clear
Date*

MonthDayYear
Date
Authorized Signature of Lisa’s Thermography and Wellness
Date*

MonthDayYear
Date
Should be Empty:

Men's Full Body

Head & Neck

Chest, Heart & Lungs

Abdomen & Lower Back

Legs & Feet

Arms & Hands

Hips

Client Disclosure

Authorization to Use or Disclose Protected Health Information