Enter the patient's name with the same name used to name the images, and complete the following form:
   
DOB:
Exam:  
Use today's date: 
Does patient report physical symptoms of breast disorder?
Right:
Left:
     Asymptomatic?
Dominant symptom on the right breast:
Irritation   Burning   Pain   Numb   Palp Mass   Physical Distortion

In what region of the right breast is the reported symptom?
Upper-Outer    Upper-Inner    Lower-Outer    Lower-Inner    Nipple/Areola at O'clock
Dominant symptom on the left breast:
Irritation    Burning   Pain   Numb    Palp Mass   Physical Distortion

In what region of the left breast is the reported ?
Upper-Outer   Upper-Inner   Lower-Outer   Lower-Inner   Nipple/Areola at O'clock
Does patient have history of any type breast cancer, biopsy, or radiation therapy to chest?     No    Yes
Enter the procedure and its location, in the Submitter's Comment, below. (Ex: Lumpectomy, upper-inner right breast.)
Have any of patient's 1st-degree relatives (mother, sisters, daughters) had breast cancer?     No    Yes
Enter the relationship and any pertinent health history, in the Submitter's Comment, below. (Ex: Sister/breast cancer.)
Does patient have either a BRCA1 or BRCA2 gene, or heritage elevating risk?     No    Yes    Unknown
Adherence to a strict pre-examination protocol significantly enhances the accuracy of the thermographic evaluation and assures accurate comparative evaluations for serial examinations.
Pre-examination parameters are considered by this program in evaluating the thermographic information. Deviation from the recommended protocol could result in profound and misleading changes in the thermal characteristics of the breast, and should be recorded for maximum accuracy of analytical results.
The following comply with recommended protocol:
1) Patient did not ingest alcohol or caffeine within 24-hours of the examination.
2) Patient is not pregnant, ovulating or experiencing systemic illness.
3) Patient did not smoke cigarettes nor had hot/cold beverages within 2-hours of exam.
4) The exam should not be performed during the follicular phase of patient's menstrual cycle
(days 6 - 13 after cessation of menses).
5) Serial examinations should always be performed at the same time of day.
6) Thermal equilibration should be conducted for a minimum of ten minutes (preferably 15-minutes)
with the pre-examination and examination room(s) temperature(s) between 68°F - 72°F.
Close
Was examination performed consistent with the TAS Breast Examination Protocol?Yes   No       ? 
Did patient ingest alcohol or caffeinated beverages within 24-hours before this examination?
No    Yes    
Did patient use nicotine or ingest hot/cold beverages within 2-hours before this examination?
No    Yes    
Is patient pregnant, ovulating or experiencing a systemic elevated temperature?
No    Yes    

Was this examination conducted during follicular phase of patient's menstrual cycle?
No    Yes    
Exam performed:  AM  PM  
Preparation/Examination Room Temp?   ≤67°F    68°F - 72°F     ≥73°F   

Patient was thermally equilibrated for:
     < 5 min.     5 - 10 minutes     10 - 15 minutes     > 15 minutes    
Submitter's Comments:  Briefly identify and locate any observed surface scars and artifacts, surgical procedures, or any issues potentially influencing the objective assessment of the submitted images:
Select and Add the Image Files to Upload:     

To select the image files for uploading click the 'Select' button, below, to launch the file selection dialog.

Select ALL files that you desire to submit. They will be simultaneously uploaded.

Select the multiple files in a variety of ways:

  • Hold down the Ctrl key and click the left mouse button on each file you want to select.
  • Select the first file with the mouse, then hold down the Shift key and click on the last file.
  • Select all files by selecting the first file with the mouse, and then pressing Ctrl-A.
Close