|
Have you been diagnosed with breast cancer?
|
Date of Breast Cancer Diagnosis
|
|
|
Which breast was diagnosed with cancer?
|
|
|
|
|
Date of your last mammogram
|
Mammogram results
• • •
|
|
Date of your last breast ultrasound
|
Ultrasound results
• • •
|
|
Were both breasts imaged?
|
Was a biopsy recommend?
|
|
Date of your last breast exam by a doctor
|
Breast exam results
• • •
|
|
Are you pregnant?
|
Are you currently nursing?
|
|
Select symptoms you are currently experiencing
• • •
|
Left & Right Breast Diagram
|
|
|
|
|
Re-Exam (On = yes)
|
Tech Signature
|
|
Span High Temp (°C)
|
Span Low Temp (°C)
|
|
Patient Temperature (°F)
|
Room Temperature (°F)
|
