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Thermographic Health Advantage
Preventative Health Screening Designed for Your Well-Being
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Patient Intake Form for Men
This form must be completed for all new and existing clients male clients.
Name
*
First Name
Last Name
Date of birth
*
Address
*
City
*
State
*
Zip Code
*
Email Address
*
Cell Phone
*
Please include area code.
(###)
###
####
Home Phone
Please include area code.
(###)
###
####
Have you received the CoVid Vaccine or Booster?
*
It is recommended that all thermography clients wait at least 4 weeks after their last vaccine before scheduling an appointment.
Yes
No
Vaccine administered in
*
Left Arm
Right Arm
Not vaccinated
Date of Last Vaccine or Booster
MM
DD
YYYY
What is your current age?
*
Occupation
*
Name of Primary Doctor
*
Name of referring physician or practitioner
*
Would you like your report and images emailed to your physician or practitioner?
*
Yes
No
Please provide the email Address of your physician or practitioner to send your thermography images and reports to
Do you have an annual physical by your physician?
*
Yes
No
Primary Health Concerns
*
What are your primary health concerns and reason for todays visit?
Have you ever been diagnosed with any or had any of the following conditions? Please check all that apply
*
Allergies
Anemia
Arthritis
Asthma
Blood Disorder
Cancer
Carpal Tunnel
Chronic Sinusitis
Circulatory Issues
COPD
Crohn's Disease
Diabetes
Diverticulitis
Fibromyalgia or Chronic Fatigue
GERD
Graves Disease
Hashimoto's
Headache or Migraine
Heart Disease
Herniated Disc
High Blood Pressure
High Cholesterol
Hyperthyroid
Hypothyroid
IBS or IBD
Immune Dysfunction
Kidney Disease
Liver Disease
Lung Disease
Multiple Sclerosis
Neurological Disorder
Neuropathy
Numbness or Tingling in Arms
Numbness or Tingling in Legs
Osteoarthritis
Pulmonary Disease
RSD
Skin Conditions
Spinal Stenosis
Stroke
Thyroid Disease
TMJ
Ulcerative Colitis
None
Current Symptoms
*
What do you do or take to relieve your pain or symtoms?
*
Current Treatments
*
Current Medications
*
Date of last thermogram
MM
DD
YYYY
Results or findings from prior health tests or screening - Sonogram, Thermogram, MRI, CT Scan, Blood Tests or X-Ray
*
Please bring a copy of any pertinent test and surgical reports.
Surgical History
*
Health History
*
What illnesses have you had over the course of your life?
Please provide additional information for the conditions you mentioned above.
*
Do you have any frequent or chronic pain, or any discomfort in your body?
*
Are you experiencing any numbness or the sensation of pins and needles anywhere on your body?
*
Dental Surgical History
*
Extractions
Root Canal
Implant
Other Oral Surgery
None
Have you had any dental procedures or a dental cleaning in the past week?
*
It is recommended that you wait one week after a dental cleaning and longer if you’ve had any recent dental surgery (implant, extraction, root canal)
Yes
No
Do you have any swelling in the neck area or have trouble swallowing?
*
Yes
No
Do you frequently have to clear your throat?
*
Yes
No
Family Medical History: medical conditions and/or diagnosis of any family members
*
Are there any relatives who were diagnosed with cancer
*
Smoking History
*
Smoking includes, vaping, recreational and medical use of cannabis
Current Smoker
Never smoked
Not smoked in last year
Not smoked in last 5 years
Not smoked in last 10 years
Not smoked in last 20 years
Skin lesions or abnormalities
*
Have you ever had chemotherapy or radiation treatments?
*
For radiation treatments please indicate the site and diagnosis.
Yes
No
Date of Last chemotherapy or radiation treatment
MM
DD
YYYY
Have you ever received hormone therapy?
*
Yes
No
Do you suffer from fatigue?
*
Sometimes
Frequently
Never
Do you have a low libido?
*
Yes
No
Do you have night sweats?
*
Yes
No
Does Thermographic Health Advantage have your permission to use texting and email as a means of communication?
*
Texting would primarily be used for appointment reminders, to clarify information regarding your health history, or additional information concerning your thermography appointment. You can update and change your preferences at any time via email or text.
Yes, I give permission to use texting as a means of communication with Thermographic Health Advantage.
Yes, I give permission to receive copies of my reports and images via email, and as a means of communication with Thermographic Health Advantage.
Yes, I give permission to receive automated email reminders for my follow-up and annual thermography studies.
No, I do not give permission to use texting as a means of communication with Thermographic Health Advantage.
No, I do not give permission for Thermographic Health Advantage to send copies of my report and images via email, or as a means of communication.
No, I do not wish to receive automated reminders for follow-up and annual thermography studies.
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 Thermography 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. Breast thermography screening is an adjunctive test to mammography, ultrasound, and MRI and is a specialized physiological test designed to detect angiogenesis, hyperthermia from nitric oxide, estrogen dominance, lymph abnormality, and inflammatory processes including inflammatory breast disease, all of which cannot be detected with structural tests.
By checking this box, I certify that I have read and understand the statements above and consent to the examination and that the above information is correct to my knowledge.
Thank you! Your form has been submitted.