Patient Information

Choose Your Lab

Please select the BTI lab where you plan to have your thermography scanrequiredHave you had thermography before?requiredHow did you hear about us?requiredWho may we thank for referring you?

If you were referred to BTI by another practitioner, please note their name and title here.

Required Protocols for Thermal Imaging

Patient Preparation:

Thermal imaging is a heat sensitive test. Anything which creates heat should be avoided prior to testing. Excessive metabolic activity, friction, or any of the activities listed below which will alter heat readings.

1 Month Prior:

No minor breast surgery, i.e. biopsy.
We may still perform testing after biopsy. Write this in your intake form.
Patients MUST wait a minimum of 4-6 weeks after CoolSculpting procedures BEFORE having thermal imaging.
Patients should wait 6 weeks after Cupping BEFORE having thermal imaging.

1 Week Prior:

Be cautious of too much sun exposure in order to avoid sunburn. Scans will have to be rescheduled if the patient has a sunburn of any sort.

48 Hours Prior:

For best results, men should shave facial hair and excessive back hair.
Avoid all tanning and limit sun exposure.

24 Hours Prior:

Avoid chiropractic care, massage therapy or acupuncture.
No saunas, steam baths, hot tubs, heating pads, or hot water bottles.
No analgesic creams or balms.
Do not shave underarms (should be done prior).
Please reschedule if you are feeling feverish or ill in any way.
Refrain from sexual activity.

Day of Exam:

Do not use creams, lotions, cosmetics, ointments, deodorant, antiperspirants, powders or any other skin product.
Please bring a hair tie to remove hair from your forehead and back of neck.
Remove all piercings and jewelry prior to exam, unless unable to.

4 Hours Prior:

Women – do not wear a bra for the 4 hours leading up to the exam.
Avoid hot showers or shaving.
Avoid physical therapy or exercise.
No coffee, tea, soda, or other beverages containing caffeine. No alcoholic beverages.
Do not smoke cigarettes or use any product which contains nicotine.
Do not use a seat warmer.

2 Hours Before the Exam:

Avoid hot or cold liquids.
Avoid eating or chewing gum.
Avoid using a cell phone to ear. You can still text, use the speaker, and GPS.
Do not use a smart watch.

Prior to and During Exam:

Please inform us if you have a hot flash during the session.
Try to relax prior to and during the exam. Stress will affect your exam.

I have read the the protocols required for this method of screening and will adhere to the protocols beginning 24 hours prior to my exam.required

Thermography Patient Protocols

Head/Neck

Do you currently have any cold symptoms or congestion? Have you had any neuromodulator injections (e.g., Botox, Dysport, Xeomin) within the past three months? Do you have, or have you ever been diagnosed with, any neurological disorders or undergone neurological surgery?

Do you have a family history of strokes?required

Do you have, or have you ever been diagnosed with, any ear, nose, or throat (ENT) disorders or undergone ENT surgery?

Breast Health

Have you ever had a mammogram?required Have you had a breast ultrasound?required Have you had a breast MRI?required Have you had a breast biopsy?required

Breast & Chest 1

Do you have breast or chest concerns?

Recent Breast Symptoms: check all that apply
	Left	Right
Change in Breast Size
Areas of skin thickening or dimpling
Excretions of the nipple

Click areas affected

Pain

Lump

Cyst

Clear

Breast & Chest 2

Do you have any family history of breast cancer?requiredHave you ever been diagnosed with breast cancer?required

Have you ever been diagnosed with any other breast disease?

Do you have or have you been diagnosed with any female-specific hormonal health conditions?

Chest

Do you have, or have you ever been diagnosed with, any cardiovascular disorders or undergone cardiac surgery? Do you have, or have you ever been diagnosed with, any respiratory disorders or undergone thoracic surgery? Do you have, or have you ever been diagnosed with, any vascular disorders or undergone vascular surgery?

Abdomen

Do you have, or have you been diagnosed with, any abdominal or digestive disorders or undergone surgery? Do you have, or have you been diagnosed with, any kidney disorders or undergone surgery? Have you had any gynecological (GYN) surgery?

Spine

Do you have, or have you ever been diagnosed with, any spinal disorders or undergone spinal surgery? Do you have, or have you been diagnosed with, any musculoskeletal disorders or conditions? This includes issues related to bones, joints, muscles, tendons, and ligaments.

Upper Extremeties

Do you have, or have you been diagnosed with, any of the following conditions related to your upper extremities?

Lower Extremeties

Do you have, or have you been diagnosed with, any of the following conditions elated to your lower extremities?

Skin

Do you have, or have you ever been diagnosed with, any dermatological conditions or undergone skin surgery?

Other

Have you ever been diagnosed with any of the following?

Please check all that apply

Lifestyle Factors

Please check all that apply

Other Health Concerns or Symptoms

Privacy Practices and Statement of Understanding

This analysis was performed at the request of the patient or a referring physician. It is an analysis of infrared heat mapping of the skin surface temperatures. The analyses performed are based on the interpreter’s impressions without seeing the patient in person. Some of the findings may be due to artifacts or obvious benign issues that should be dismissed as pathology based on you clinical investigation. Relevant comments are made to direct the physician in clinical management. This important tool should be used in addition to the physician’s other diagnostic tools to create a complete clinical impression. The areas highlighted represent areas of concern that may need to be investigated by clinical correlation and other testing. This may include a physical exam, palpation, radiology, metabolic testing, or other traditional diagnostic methods. Thermographic imaging is a screening test that alerts of possible areas of pathology at the indicated levels. Normal variants are also common. Sometimes pathological findings appear earlier than traditional tests. Close thermal follow-up is highly recommended over time.

Privacy Practices and Informed Consent

This covered entity is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.

For purposes of this notice, the term "covered entity" refers to Thermographic Wellness, INC, Breast Thermography International INC, The Professional Academy of Clinical Thermology, the testing doctor, the interpreter, the testing facility, the technician(s), and any person involved in the proposed exam.

You have rights concerning your private health information, your access to this information and to know how this information is used by our office. You also have rights related to our ability to contact you concerning your activity in our practice, such as recall reminders, billing and other matters related to how we communicate with you and others on your behalf. Please understand that this office, along with all its employees and associates, makes every effort to keep your private medical information confidential at all times. Such information will only be shared with others with your explicit consent.

A. The covered entity may contact the individual to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to the individual.

B. Your information will not be shared with any third party without your express written consent. Your images will be interpreted by outside interpreters and consultants, and you hereby grant permission for this purpose. Files will be transferred by email, server upload, and other forms of electronic transfer. Files may be non-encrypted. Files may be relayed for second opinion to colleagues. Your information may be used for academic purposes, at which point no names, or other identifiable information will be demonstrated.

C. Your records are available to you for review, copying or corrections by appointment and you will not be denied access to your personal health information. Any changes you request to your personal health information must be supplied to this office in writing and you will be advised within 30 days of any objection to the correction, or that the correction has been made.

D. With respect to other providers requesting your personal health information, we will require a written authorization for the release of medical records signed by you, detailing the name, address, and phone number of the requesting physician. Under no circumstance will we discuss your personal health information with anyone.

Your interpreted report will be available to you through the patient portal upon its completion. If you do not see your report in the portal within 14 business days from the date of your scan, please contact patientsupport@btiscan.com.

Full Namerequired

Type your first name and last name as they appear on the intake form to sign electronically.

Signaturerequired

Version 2.0.6

Patient Intake Form