Please fill out the entire form even if only getting a breast scan as it could be relevant to your results.
*Required fields
Patient is expected to thoroughly complete each field to the fullest extent. upon
review, the staff may return based on incomplete documentation. Interpretation will
not be completed without adequate completion of this document.
Mandatory Protocols for Thermal Imaging
Patient Preparation:
Thermal imaging is a heat sensitive test. Anything which creates heat should be avoided prior to testing.
Excessive metabolic activity, friction, or any of the activities listed below which will alter heat readings.
1 Month Prior:
No minor breast surgery, i.e. biopsy
We may still perform testing after biopsy. Write this in form.
1 Week Prior:
Be cautious of too much sun exposure in order to avoid sunburn. Scans will have to be rescheduled if the patient has a sunburn of any sort.
48 Hours Prior:
Men with beards should shave their face and neck, as well as backs
Avoid all tanning and limit sun exposure
24 Hours Prior:
Avoid chiropractic care, massage therapy or acupuncture
No saunas, steam baths, hot tubs, heating pads, or hot water bottles
No analgesic creams or balms
Do not shave underarms (Should be done prior).
Reschedule if you experience a significant fever.
Refrain from sexual activity
Day of Exam:
For best results, please wear thong underwear or a jock strap for full body studies. Underwear is optional and best results are without.
Do not use creams, lotions, cosmetics, ointments, deodorant, antiperspirants, powders or any other skin product.
Please bring a hair tie to remove hair from your forehead and back of neck.
Remove all piercings and jewelry prior to exam, unless unable to.
4 Hours Prior:
Avoid hot showers or shaving
Avoid physical therapy or exercise
No coffee, tea, soda, or other beverages containing caffeine. No alcoholic beverages.
Do not smoke cigarettes or use any product which contains nicotine
Women- do not wear a bra for the 4 hours leading up to the exam
2 Hours Before the Exam:
Avoid hot or cold liquids
Avoid eating or chewing gum
Avoid using a cell phone
Prior to and During Exam:
Please inform us if you have a hot flash during the session
Try to relax prior to and during the exam. Stress will affect your exam.
*I have read the the protocols required for this
method of screening and will adhere to the protocols beginning 24 hours prior to
my exam.
Breast & Chest 1
*Breast/Chest Concerns
If you have a pending biopsy, note the proposed location (left or right breast, clock
face numerical reference). If you have no concerns regarding this area, please enter
"no concerns".
Recent Breast Symptoms: check all that apply
Left
Right
Change in Breast Size
Areas of skin thickening or dimpling
Excretions of the nipple
Click areas affected
Pain
Lump
Cancer
Clear
Breast & Chest 2
*How many mammograms have you had?
*Date of last anatomical study (mammogram, MRI, ultrasound)
*What were the results of your Mammography?
*Have you ever been diagnosed with breast cancer?
Date of diagnosis
If yes, what type?
Breast & Chest 3
What type of treatment did you receive?
What kind of Hormone Therapy are you taking?
If you have other breast disorders or procedures, please list type, location, date, treatment, and results
Surgical History (Please list type, location, date, treatment, and results)
General Medical History
Please check all that apply
HysterectomyBreast ImplantsContraceptive PillsOther Breast Disorders/ProceduresHormone Replacement TherapyCurrently Breastfeeding
Testicles
Have you noticed any lumps in your testicles?
Problems related to
ProstateTesticlesPenis
Head & Neck
Please check all that apply
AllergiesTMJHeadachesThyroid DisorderSinus ProblemsNeck PainCurrent ColdAsthmaBleeding GumsSmokeRecent Dental WorkCarotid Artery DiseaseDental ProblemsPersonal/Family History of Stroke
*Specific Concerns
If you have no concerns regarding this area, please enter "no concerns".
Abdomen & Spine
Please check all that apply
Upper back painLower back painScoliosisAcid Reflux
Pain
StomachRight ChestLeft ChestPelvisAbdomen
Surgical History (Please list type, location, date, treatment, and results)
*Specific Concerns
If you have no concerns regarding this area, please enter "no concerns".
Upper Extremeties
Please check all that apply
Left ShoulderRight ShoulderLeft ElbowRight ElbowLeft ArmRight ArmLeft HandRight Hand
Surgical History (Please list type, location, date, treatment, and results)
*Specific Concerns
If you have no concerns regarding this area, please enter "no concerns".
Surgical History (Please list type, location, date, treatment, and results)
*Specific Concerns
If you have no concerns regarding this area, please enter "no concerns".
HIPAA and Statement of Understanding
This analysis was performed by the request of this patient or a referring physician.
It is an analysis of infrared heat mapping of the skin surface temperatures. The
analyses performed are based on the interpreter’s impressions without seeing the
patient in person. Some of the findings may be due to artifacts or obvious benign
issues that should be dismissed as pathology based on you clinical investigation.
Relevant comments are made to direct the physician in clinical management. This important
tool should be used in addition to the physician’s other diagnostic tools to create
a complete clinical impression. The areas highlighted represent areas of concern
that may need to be investigated by clinical correlation and other testing. This
may include physical, exam, palpation, radiology, metabolic testing, or other traditional
methods of diagnosing. Thermographic imaging is a screening test that alerts of possible
areas of pathology at the indicated levels. Normal variants are also common. Sometimes
pathological findings appear earlier than traditional tests. Close thermal follow-up
is highly recommended over time.
HIPAA Compliance and Informed Consent
This covered entity is required by law to maintain the privacy of protected health
information and to provide individuals with notice of its legal duties and privacy
practices with respect to protected health information.
For Purposes of this notice, the term "covered entity" refers to Thermographic Wellness,
INC, Breast Thermography International INC, The Professional Academy of Clinical
Thermology, the testing doctor, the interpreter, the testing facility, the technician(s),
and any person involved in the proposed exam.
You have rights concerning your private health information, your access to this information
and to know how this information is used by our office. You also have rights related
to our ability to contact you concerning your activity in our practice, such as recall
reminders, billing and other matters related to how we communicate with you and others
on your behalf. Please understand that this office and each and all of its employees
and associates make every effort possible to keep confidential your private medical
information at all times and with your consent only, will such information ever be
shared with others.
A. The covered entity may contact the individual to provide appointment reminders
or information about treatment alternatives or other health related benefits and
services that may be of interest to the individual.
B. Your information will not be shared with any third party without your express
written consent. Your images will be interpreted by outside interpreters and consultants,
and you hereby grant permission for this purpose. Files will be transferred by email,
server upload, and other forms of electronic transfer. Files may be non-encrypted.
Files may be relayed for second opinion to colleagues. Your information may be used
for academic purposes, at which point no names, or other identifiable information
will be demonstrated.
C. Your records are available to you for review, copying or corrections by appointment
and you will not be denied access to your personal health information. Any changes
you request to your personal health information must be supplied to this office in
writing and you will be advised within 30 days of any objection to the correction,
or that the correction has been made.
D. With respect to other providers requesting your personal health information, we
will require a written authorization for the release of medical records signed by
you, detailing the name, address, and phone number of the requesting physician. Under
no circumstance will we discuss your personal health information with anyone.
Your interpreted report will be provided to you by your Technician upon its completion. If you do not receive your report within 14 business days from the date of your scan, please contact patientsupport@btiscan.com
.
*Full Name
Type your first name and last name as they appear on the intake form to sign electronically.
*Signature
Sorry, there was an error submitting the data. Please try again in a few moments.
Finished
Thank you for the form submission. We are looking forward to being your thermography lab.
Be sure to follow all the recommended protocols listed
on the form. For a list of these please vistThermography
Patient Protocols.Print for your records