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No referral or order needed! SELF-REFERRED Mammograms Now Available!
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Dexa
CT scan
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MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
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Careers
Portals
Patient Portal
Physician Portal
Contact Us
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Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
For Patients
Order Form
Patient Forms
Medical Records
Insurance
FAQ
Careers
Portals
Patient Portal
Physician Portal
Contact Us
Breast Questionnaire
"
*
" indicates required fields
Date of Service
*
MM slash DD slash YYYY
Ordering Provider
*
Patient Name
*
First
Last
DOB
*
MM slash DD slash YYYY
Personal History
Date of Last Mammogram
*
MM slash DD slash YYYY
Date of Last Mammogram
*
NORMAL
ABNORMAL
Location/Site
*
Have you had a prior Breast MRI?
*
YES
NO
Have you had a prior Breast Ultrasound?
*
YES
NO
Reason for today’s exam: (Mark one)
*
Baseline (no prior mammogram)
Routine Yearly Exam
Short Term Follow-Up
Problem-Related
Current Symptoms?
*
YES
NO
Discovered by:
*
SELF
DOCTOR
N/A
Lump?
*
YES
NO
Pain?
*
YES
NO
Lump?
*
YES
NO
Other?
*
Are you possibly pregnant?
*
YES
NO
Date of last menstrual cycle
*
MM slash DD slash YYYY
Date of last physical breast exam
*
MM slash DD slash YYYY
In the last 6 months, have you taken
*
Hormones
Birth Control Pills
N/A
In the last 6 months, have you:
*
Breast Feeding
Lost Weight
N/A
Have you been diagnosed with any of the following?
*
Breast Cancer
Ovarian Cancer
LCIS
Atypical Hyperplasia
Other
Other?
*
Patient Name
*
First
Last
DOB
*
MM slash DD slash YYYY
Personal Surgical History
Previous Breast Procedures?
*
YES
NO
Previous Breast Procedures Options
*
Cyst Aspiration
Needle(Core) Biopsy
Biopsy in Radiology Suite
Biopsy in Operating Room
Breast Reduction or Lift
Implants
Malignant Lumpectomy
Mastectomy
Cyst Aspiration
*
RT
LT
Benign
Malignant
Date
*
MM slash DD slash YYYY
Needle(Core) Biopsy
*
RT
LT
Benign
Malignant
Date
*
MM slash DD slash YYYY
Biopsy in Radiology Suite
*
RT
LT
Benign
Malignant
Date
*
MM slash DD slash YYYY
Biopsy in Operating Room
*
RT
LT
Benign
Malignant
Date
*
MM slash DD slash YYYY
Breast Reduction or Lift
*
RT
LT
Date
*
MM slash DD slash YYYY
Implants
*
RT
LT
Saline
Silicone
Date
*
MM slash DD slash YYYY
Malignant Lumpectomy
*
RT
LT
Radiation
Chemotherapy
Date
*
MM slash DD slash YYYY
Mastectomy
*
RT
LT
Radiation
Chemotherapy
Date
*
MM slash DD slash YYYY
Family Medical History:
Has anyone in your family been diagnosed with Breast Cancer?
*
YES
NO
If Yes, specify whom and give age of diagnosis (include maternal and paternal)
*
Mother
Sister
Grandmother
Father
Aunt
Cousin
Daughter
Has anyone in your family been diagnosed with Ovarian Cancer?
*
YES
NO
I have personally completed the above questionnaire. Should the results of my mammogram require any type of surgical follow-up, I authorize Premier Mountain Imaging Center to obtain pathology results from my doctor, hospital and/or surgeon in accordance with FDA under MQSA guidelines.
Patient Signature (or person authorized to sign):
*
Date
*
MM slash DD slash YYYY
Relationship to patient if signing for patient:
*
