Download Is a full body thermogram right for you?

Is a full body thermogram right for you?
A complete body thermogram provides an extremely unique way of evaluating
the physiology of the body. It can provide clues or early warning signs of many
conditions that standard imaging cannot always identify. Since it uses no
radiation and there is no discomfort, the test can be used as often as needed.
If you have a suspicion, family history or personal
history of any of the below problems, you may wish
to consider having a full-body thermogram to
identify possible signs and risks.
Altered gait manifestations
Arteriosclerosis
Asthma
Brachial Plexus Injury
Breast Disease
Bursitis
Carotid Artery Insufficiency
Carpal Tunnel Syndrome
Chronic pain
Compartment Syndromes
Complex Regional Pain
Syndrome (CRPS)
Diabetes
Disc Syndromes (spinal
discogenic pain)
Facet Syndrome
Fibromyalgia
Gallbladder Disease
Headache Evaluation
(cervicogenic, migraine, sinus)
Herniated Disc/Ruptured Disc
Hypoesthesia
Hyperesthesia
Inflammatory Diseases
Intervertebral Disc Disease
Ligament Tears
Lower Motor Neuron Disease
Lumbosacral Plexus Injury
Lupus (SLE)
Muscular Spasm
Muscle Tears
Myofascial Irritation
Myofascial Pain Syndrome
Nerve Entrapment
Nerve Impingement/Pressure
Nerve Root Irritation
Nerve Stretch Injury
Nerve Trauma
Neuritis
Neuropathy
Neurovascular Compression
Paresthesia
Peripheral Nerve Abnormalities
Pinched Nerves
Referred Pain Syndromes
Reflex Sympathetic Dystrophy
(RSD/CRPS)
Repetitive Strain Injuries
Respiratory Conditions
Reynaud’s Disease
Rheumatoid Arthritis
Sacroiliac Ligament Tear
Sacroiliac Syndrome
Sensory Nerve Abnormalities
Sinus Conditions
Skin Abnormalities
Soft Tissue Injury
Spinal Cord Pain/Injury
Sports Injuries
Stomach Conditions
Strain/Sprains
Stroke Warning
Superficial Vascular Disease
Synovitis
Temporal Arteritis
Tendonitis
Thoracic Outlet Syndrome
Thyroid Conditions
TMJ Dysfunction
Trigeminal Neuralgia
Trigger Points
Whiplash Conditions
Thermography - New Patient Consent Agreement
Instructions: All information is confidential and is used by the physician to evaluate your thermal images. Complete
all paperwork prior to your arrival. If this is not possible, arrive fifteen minutes early for your appointment and
complete the necessary paperwork at that time. If you have questions, call Activecare Thermography at 814-8644100. Please read the following carefully and initial your name on the line at the beginning of each section:
________I understand that thermography is a procedure utilizing infrared imaging cameras to visualize and obtain an image of the infrared
heat coming off the surface of the skin. Since infrared imaging only detects heat at the surface of the body, the technology cannot see
into the cranial vault, thoracic cavity, or deep into the body to visualize organs or bones. I understand that this procedure does not use
radiation, is not harmful to me, the equipment does not touch my body, and that its sole function is to produce an image of the heat
coming off my body. The thermographic procedure is performed in order to analyze temperature patterns on the body that may or may
not indicate the presence of an abnormal process. Consequently, a normal thermogram does not rule out the presence of significant
pathology. All thermography reports are meant to identify heat patterns that suggest potential risk markers only and do not in any way
suggest diagnosis and/or treatment. Your thermogram report is meant to be used by your treating doctor as an adjunctive aid in the
assessment of your health. The report is not to be used for self-diagnosis and/or treatment.
________I understand that infrared imaging of the breast is not intended as a replacement for or alternative to mammography, ultrasound,
MRI or any other form of imaging. Thermography is not a stand-alone screening tool, meaning that it is not to be used by itself for
screening. I understand that infrared imaging of the breasts and mammography do not provide the same information on breast tissues;
and therefore, provide different values on breast tissue assessment (thermography looking for physiological changes and mammography
looking for anatomical changes).
________I understand that the doctor and/or technician providing the infrared imaging, and the doctor interpreting the images, are not
diagnosing and/or treating breast abnormalities. Follow up care relating to treatment must be done by properly trained and licensed
health care specialists.
________I understand that if, by any chance, a questionable thermal finding is discovered on my thermogram, I will comply with any and
all follow-up or referral recommendations made on my report; such as following up with an ultrasound / mammogram / MRI / etc. or with
my primary care doctor to ensure I receive proper care.
________I understand that I will be disrobed for approximately 20-30 minutes from the waist up breast exams and buttocks exposed for
lower body exams. I understand the technician (who may be male) must perform a brief visual inspection of the area(s) to be imaged.
________I understand that thermography reports do not in any way suggest diagnosis and/or treatment. No surgical procedure should
be based on thermal imaging alone. Additional procedures, which depend on the nature of the condition and/or body region, are needed
to achieve a final diagnosis.
________I understand that thermography must not be confused with CT, MRI, or other types of body imaging. These are structural
imaging technologies that look for the physical presence of tumors and other structure changes inside the body. Thermography does not
provide this type of imaging; and as such, cannot be used to screen for the spread of cancer (metastasis).
________I understand that the results of my thermograms may be made available to my doctors and others as I so designate for further
analysis in the overall evaluation of my health.
________Having understood the above, and having received satisfactory answers to any and all questions that I may have had
concerning the purpose and outcome, risk factors and benefits of thermography, I hereby consent to both initial and all subsequent
infrared imaging.
________I AGREE or ________DO NOT AGREE to allow Activecare Physical Therapy (Activecare Thermography) to use my images
for educational and marketing purposes as long as the images remain unidentifiable and my identity remains hidden.
________I AGREE or ________DO NOT AGREE that Activecare may digitally send me, via e-mail, my reports/images with understanding
that security cannot be guaranteed. I agree that should a privacy breach occur; Activecare Physical Therapy shall be held innocent.
________I have also been given pre-imaging instructions (below) to follow and I acknowledge that I have fully
complied with the preparation protocol prior to imaging:
Preparation protocol for all infrared imaging:
2
hours
Complete all bathing 2 hours prior to exam time.
4
hours
Avoid all forms of exercise other than normal walking.
4
hours
Avoid smoking, caffeine, other forms of nicotine or stimulants.
4
hours
If allowed by your prescribing physician, stop all pain medications for 4 hours prior to exam.
16
hours
Do not use lotions, powder, deodorant, antiperspirant, perfume, makeup, scented products, perfume or
anything topical on the body area to be imaged the day of your exam.
24
hours
1
12
weeks
weeks
O ffice
U se
O nly
Avoid bodily treatments: physical therapy, chiropractic, acupuncture, TENS, physical therapy, electrical
muscle stimulation, ultrasound, hot or cold pack use, waxing, exfoliating, laser or other skin
treatments/spa treatments.
Avoid excessive sun exposure, especially sun-burn, on the areas being scanned.
Notify us if you have had any medical procedures in the last 12 weeks.
Additional breast preparation protocol:
1
24
24
4
8
hours
hours
hours
weeks
weeks
Avoid breast feeding.
Avoid shaving the armpits or other areas to be imaged.
Avoid physical stimulation of the breasts.
You must wait 4 weeks after a needle biopsy before a valid thermogram can be performed.
You must wait 8 weeks following a lumpectomy before a valid thermogram can be performed.
For the exam, you will need to disrobe to expose the areas to be imaged and acclimate to room temperature (68°) for fifteen minutes prior
to your scan. The scan will take an additional fifteen to thirty minutes. If you are disabled or unable to sit or stand for long period, notify
the scheduling technician.
If you have any questions or concerns, please let us know beforehand if possible so that we may address them with you. Test Results:
Once your scan in complete, it will take approximately 14 days before your results will be available. We will email you your results and
mail a copy as well. Your scan results will include a recall period from six weeks to twelve months.
We encourage, but don’t require, you to bring a companion or partner to be present during the exam. It is non-invasive and non-contact.
The total time necessary to complete the procedure is approximately forty-five minutes.
Patient’s (Guardian’s) Name: ___________________________________________
Initials: _______ Date: _____________
Patient’s (Guardian’s) Signature: ________________________________________
Date: __________________
Witness: ____________________________________________________________
Date: __________________
NOTE: Complete only if your scan includes the breasts
Patient’s Name:
Address:
Phone #:
Email:
Date:
State:
Age:
City:
Date of Birth:
Have you ever been diagnosed with breast cancer?  Y  N Date:
Zip:
Sex:
 R  L Breast
Do you have a family history of breast cancer? If yes, who?
Date of your last mammogram:
Was it:  Normal  Abnormal  Suspicious  Watchful –  R  L Breast
Date of your last breast ultrasound:
Were both breasts imaged?  Y  N
Was it:  Normal  Abnormal  Suspicious  Watchful –  R  L Breast
Was a follow up biopsy recommended after your LAST mammogram, ultrasound, or MRI?  Y  N
Date of last breast exam by a doctor:
 Normal  Lump  Thickening –  R  L
Any tests recommend after this last breast exam? (ex. mammogram)
Date of any breast biopsies:
 R  L Breast
What was found on the biopsy?  Cancer  Other
 R  L Breast
Any breast surgeries? Date and what was done?
 R  L Breast
Have you had a mastectomy?  Complete  Partial Date:
 R  L Breast
Was the nipple removed?  Y  N Was the surface skin of the original breast entirely removed?  Y  N
Any breast reconstruction? What was done? (ex. trans flap, implant)
 R  L Breast
Any breast radiation treatment? Date of last treatment
 R  L Breast
Are you currently pregnant?  Y  N
Are you currently nursing?  Y  N
Are you CURRENTLY experiencing any of the following with your breasts:  None
 Lump  Thickening (date found
; found by  Self breast exam  Doctor exam)
Pain:  Dull  Sharp  Burning  Stinging  Tenderness  The pain changes with my cycle
 Thickening
 Skin changes ( Color  Texture  Over the lump)
 R  L Nipple discharge ( Bloody  Milky  Clear  Through 1 duct  Through multiple ducts)
 R  L Nipple retraction ( For many years  Recently)  R  L Nipple changes ( Color  Texture)
 Other
On the breast image to the right, please draw an:
[ O ] on the diagram in the area of the lump
[ M ] for a finding on your mammogram / ultrasound / MRI
[ W ] for an area being watched
[ X ] in the area of pain, tenderness, or skin changes
[ # ] in the area of thickening
RIGHT
LEFT
[ +++ ] in the area of a scar
 Re-Exam
High T:
Low T:
Tech:
Pt T =
F Rm T =
C  R  L Nipple retraction  R  L Areola traction SLQ SMQ ILQ IMQ
 R  L Skin surface bulge or dimple SLQ SMQ ILQ IMQ
 R  L Skin changes SLQ SMQ ILQ IMQ
 R  L Nipple changes ( Color  Texture)  R  L Nipple discharge ( Bloody  Milky  Clear – S M)
NOTE: Complete this form if you are having images other
than breast performed
Patient’s Name:
Date:
Address:
Phone #:
City:
Date of Birth:
Your report will be sent to you by Email:
Please mark the area
and type of pain on the
drawing using the
following code:
N –Numbness
P –Pain
T –Tingling
A –Ache
S –Soreness
ST –Stiffness
Please mark all scars
using the following:
++++
What are your current complaints?
State:
Age:
Zip:
Sex:
________________________
Have you ever been diagnosed with cancer?  Y  N
Date:
Type:
What is the current status of the cancer?
Do you have any current diagnoses / diseases / conditions?  Y  N
List diagnoses / diseases / conditions:
Have you had any surgeries?  Y  N
List surgeries and dates:
Have you had any broken bones / fractures?  Y  N
List bones broken / fractures and dates:
Have you had any dental work in the past 2 months?  Y  N
Type of work and dates (give location –ex. rear upper molars):
Have you had a flu, cold, or respiratory illness in the past month?  Y  N
Do you suffer from any condition other than that which has been listed previously?  Y  N
If yes, what is it?
Signature: ____________________________________________________
Office Use Only:
Pt T:
Re-Exam:  Y  N
Tech:
F/C
Rm T:
Date: ____________________
C