Patient Questionaire

    Your Information
    To find out if MR-mammography is an appropriate exam for you, please complete this form and click "submit".

    First Name:   *Required
    Last Name:   *Required
    Phone Number:   *Required
    Email Address:   *Required
    What is your doctor's name?

    Have you had a mammogram before? Yes
    Date Location:
    Date Location:

    Have you had a breast MRI before? Yes
    Date Location:
    Date Location:
    Do you have any current breast complaints or problems?

    Right Breast Left Breast
    Lump
    Nipple Discharge
    Other

    When was your last menstrual period?

    Do you take any of the following medications?

    Birth Control Pills Hormone Replacement Fertility Drugs
    Have you ever been diagnosed with breast cancer?

    At what age were you diagnosed?
    What type of cancer did you have?
    How was it treated? Right Breast Left Breast
    Lumpectomy
    Mastectomy
    Radiation
    Chemotherapy

    Medications:

    Have you ever had ovarian cancer? Yes
    Has anyone in your family had breast cancer?

    Mother Age:
    Sister(s) Age:
    Daughter(s) Age:
    Aunt(s) Age:
    Grandmother(s) Age:
    Other Age: Relation:
    Have you ever had breast surgery?

    Breast Implants
    Breast Reduction
    Surgical Biopsy Date: Location: Results:
    Needle Biopsy Date: Location: Results:
    Cyst Aspiration Date: Location: Results:

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