Breast Intake Form


(download MSWord or download PDF)


Pre-Thermographic Imaging Instructions


(download MSWord or download PDF)


Pre-Examination Instructions

The following instructions must be strictly adhered to before you arrive for your appointment:

  • No prolonged sun exposure (especially sunburn) to the breasts 5 days prior
    to your exam.

  • No use of lotions, creams, powders, or makeup on the breasts the day of the exam.

  • No shaving or other hair removal of the areas to be imaged the day of the exam.

  • No use of deodorants or antiperspirants the day of your exam.

  • No treatment (chiropractic, acupuncture, TENS, physical therapy, electrical muscle stimulation, ultrasound, hot or cold pack use) for 24 hours before the exam.

  • No physical stimulation of the breasts for 24 hourse prior to the exam.

  • No exercise 4 hours prior to your exam.

  • If bathing, it must be no closer than 1 hour before the exam.

  • You must wait at least 4 weeks after having a fine needle or core biopsy of the breast before a thermogram can be performed.

  • You must wait at least 8 weeks after having a lumpectomy or surgical biopsy of the breast before a thermogram can be performed.

  • If you have had any medical procedure within the last 12 weeks, please notify our office before coming in for your appointment.

  • If you are nursing, please try to nurse as far from 1 hour before the exam as possible.

  • If you are using pain medications, please avoid taking them for 4 hours prior to the examination. However, you must consult with the prescribing physician for his or her consent prior to any change in medication use such as this.

Please note: During the examination you will be disrobed from the waist up for both imaging and to allow the body to acclimate to the temperature of the room. A female technician will perform the imaging for you.

Surgical procedures such as implants, reductions, and biopsies do not interfere with infrared imaging. Breast thermography is perfectly safe to have during pregnancy or when nursing. The procedure may also be preformed during any part of the menstrual cycle without effecting the interpretation of the images.

If you have any further questions, please feel free to contact our center (650-361-8908).


Home