, 102

Welcome to our center. Before you arrive for your thermographic examination, certain protocols must be followed in order to ensure that your images reflect accurate information. Please read the following instructions and adhere to them as closely as possible.

No prolonged sun exposure (especially sunburn) to the body areas being imaged 5 days prior to the exam.

No use of deodorants, lotions, creams, powders, or makeup (no facial makeup for full body or upper body scans) the day of the exam.

No shaving of the areas to be imaged the day of the exam.

No treatment (chiropractic, acupuncture, TENS, physical therapy, electrical muscle stimulation, ultrasound, hot or cold pack use) or physical stimulation of the areas to be imaged for 24 hours before the exam. No exercise for 4 hours prior to the exam.

If bathing, it must be no closer than 1 hour before the exam.

If you are using pain medications, please avoid taking them for 4 hours prior to the examination.

You must consult with the prescribing physician for his or her consent prior to any change in medication use such as this.

If you are scheduled for a breast thermogram, the same protocol above applies along with no physical stimulation of the breasts for 24 hours before the exam. If you are nursing, please try to nurse as far from 1 hour prior to the exam as possible.

Please note: During the examination you will be disrobed (from the waist up for breast exams, and buttocksexposed for lower body exams) during part of the examination for both imaging and to allow for the surface temperature of the body to equilibrate with the room. A female technician is provided for all of our female patients.

We have enclosed a health history form(s) for you to fill out prior to arriving for your examination. A map to our center, along with an appointment card, has been included for your convenience. If you have copies of any other test results (i.e. mammograms, blood tests) please bring them with you. If you have any further questions, please contact our office.

Thank you, for choosing our center, and we look forward to meeting you.

Michael Martin, Lab Manager

11791 W. 112th St.Overland Park, KS 66210p 1-844-248-7463fax 1-866-548-7001 info@MRLkc.com

ThermogramClinic.com1-844-248-7463

Thermal Imaging

11791 W. 112th St., Suite 102 Overland Park, Kansas 66210 1-844-248-7463

MRL Consent to Thermographic Examination

Patient’s Name: Date:

Address: City: State: Zip:

Phone #: Age: Gender:

Thermography requested by: Self Referring Doctor:

Ph#:

Instruc ons: Please read the following carefully and, if in agreement with this consent form, sign and date it at the b m. Please feel free to ask ques ons if there is anything that you do not understand on this form. Thermography is a procedure u lizing infrared imaging cameras to visualize and obtain an image of the infrared heat coming off the surface of the skin. The thermographic procedure is performed in order to analyze temperature p erns on the body that may or may not indicate the presence of a disease process. Consequently, a normal thermogram does not rule out the presence of significant pathology. Thermography, along with X-ray, CT, MRI, mammography, ultrasonography and other imaging procedures, is not a stand-alone diagnos c tool. Like other imaging tests it is an adjunc ve tool, which while reliable should be u lized by the pa ent’s trea ng physician along with other tests and analyses to arrive at a provisional or more complete diagnosis. No surgical procedure should be based on thermal imaging alone. Addi onal diagnos c procedures, which depend on the nature of the condi on and/or body region, are needed to achieve a final diagnosis. Thermography must not be confused with EBT or CT full body scanning. EBT and CT body scanning are structural imaging technologies, which look for the physical existence of tumors and other body structure changes while thermography does not. This office provides only the thermographic component of a complete evalua on. I understand that I will be disrobed (from the waist up for breast exams, and bu cks exposed for lower body exams) during part of the examin on for both imaging and to allow for the surface temperature of my body to equilibrate with the room. I have also been informed in advance that if a female technician is not available I will be alone with the doctor in the examin on room and have the op on of bringing someone with me to the exam. My body will be imaged with an infrared camera. I understand that this procedure does not use radi on, is not harmful to me, and that its sole func on is to produce an image of the heat coming off my body. I also understand that a brief physical examin on of any suspect areas found on the thermographic images may be performed in order to fully characterize the findings. The inform on provided will be made available to my tre ng physician upon request for further diagnosis should an abnormality be detected. I have been informed about pre-examin on prepara on to insure the most accurate thermographic examina on possible, and have complied with this protocol. Having understood the above, and having received s sfactory answers to any and all ques ons that I may have had concerning the purpose and outcome, risk factors and benefits of a thermographic examin on, as well as the u liz on of the procedure, I hereby consent to both ini al and subsequent thermographic examin ons. I also understand that thermography is not a subs tute for mammography, ultrasonography, CT, MRI or any other form of diagnos c imaging. Pa ent’s (Guardian’s) Name: Date: (please print) Pa ent’s (Guardian’s) Signature: Witness:

Patientís Name: Date:

Address: City: State: Zip: _______

Phone #: Date of Birth: Age: Gender:

HABITS EXERCISE FAMILY HISTORY

r Smoking Packs/Day r None Diabetes Heart Kidney Cancer Back r Drinking Alcohol r Moderate Mother r r r r r r Coffee Cups/Day r Daily Father r r r r r Type Brother, No. of r r r r r

Sister, No. of r r r r r

HAVE YOU HAD ANY OF THE FOLLOWING DISEASES?

r Appendicitis r Anemia r Heart Disease r Arthritis r Pneumonia r Measles r Goiter r Epilepsy r Rheumatic Fever r Mumps r Influenza r Mental Disorder r Polio r Chicken Pox r Pleurisy r Lumbago r Tuberculosis r Diabetes r Alcoholism r Eczema r Whooping Cough r Cancer r Venereal Infection r HIV Positive OPERATIONS AND PROCEDURES

DATE(S) DATE(S) DATE(S) Vaccinations Tubes in Ears Sinus Tonsillectomy Appendectomy Hernia Gall Bladder Female Organs Thyroid Back Operation Rectal Surgery Stomach Other Other Other

OFFICE USE ONLY

Page 1 of 3

Health History Form

Page 2 of 3

Health History Form

Do you have any close family history (father/mother, grandparents, aunts/uncles) of any of the following:

r Thyroid problems r Diabetes r Gout r Heart conditions r Kidney problems r Ovarian/uterine problems

r Liver problems r Gallbladder problems r Stomach problems r Colon problems r Lung conditions r Strokes Have you had the flu, a cold, or a respiratory illness (cough) in the last 3 weeks? r Yes r No Do you smoke? r Yes r No When was your last smoke?: Have you experienced a recent trauma (a fall, sports injury, car accident, dental work, surgery, etc.)? r Yes r No

Are you now or have you ever been disabled? r Yes r No When: How:

Please answer the following questions in regard to the chief complaints you described on pages 1 and 3.

COMPLAINT

1: 2: 3:

When and how did this problem begin?

r suddenly r gradually r suddenly r gradually r suddenly r gradually

What makes it better ? / What makes it worse ?

How would you describe your pain/symptoms ?

r achy r sharp r burning r achy r sharp r burning r achy r sharp r burning

r sore r tight & stiff r sore r tight & stiff r sore r tight & stiff

r numb r pins & needles r numb r pins & needles r numb r pins & needles

How often do you experience your pain/symptoms ?

r constantly (100%) r frequently (75%) r constantly r frequently r constantly r frequently

r intermittently (50%) r occasionally (25%) r intermittently r occasionally r intermittently r occasionally

Does the pain radiate anywhere ?

r down the arms r legs r down the arms r legs r down the arms r legs

Is your complaint affected by the time of day ?

r worse in the morning r evening r worse in morning r evening r worse in morning r evening

r better in the morning r evening r better in morning r evening r better in morning r evening

Are you getting: (Circle) worse / better / same worse / better / same worse / better / same

Page 3 of 3

Health History FormN

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GENERAL GASTRO- EAR/NOSE/ SYMPTOMS INTESTINAL THROAT RESPIRATORY

r r r Bronchitis r r r Belching or gas r r r Asthma r r r Chest pain r r r Chills r r r Colon trouble r r r Crossed Eyes r r r Chronic cough r r r Convulsions r r r Constipation r r r Deafness r r r Difficulty breathing r r r Dizziness r r r Diarrhea r r r Earache r r r Spitting blood r r r Fainting r r r Excessive hunger r r r Ear discharge r r r Spitting phlegm r r r Fatigue r r r Gall bladder trouble r r r Ear noise r r r Fever r r r Hemorrhoids (Piles) r r r Enlarged thyroid

GENITO-URINARY r r r Headache r r r Jaundice r r r Frequent colds r r r Loss of sleep r r r Liver trouble r r r Hayfever r r r Bed wetting r r r Loss of weight r r r Nausea r r r Hoarseness r r r Blood in urine r r r Nervousness r r r Pain over stomach r r r Nasal obstruction r r r Frequent urination r r r Neuralgia r r r Poor appetite r r r Nose bleeds r r r Inability to control urine r r r Night sweats r r r Poor digestion r r r Pain in eyes r r r Kidney infection r r r Numbness/pain r r r Vomiting r r r Poor vision r r r Painful urination in arms/legs/hands r r r Vomiting blood r r r Sinusitis r r r Prostrate trouble r r r Wheezing r r r Sore throats r r r Allergy to what: r r r Tonsilitis k MUSCLES CARDIO- SKIN OR FOR WOMEN

& JOINTS VASCULAR ALLERGIES ONLY

r r r Backache r r r High blood pressure r r r Boils r r r Cramps or backaches r r r Foot trouble r r r Low blood pressure r r r Bruise easily r r r Excessive flow r r r Hernia r r r Pain over heart r r r Dryness r r r Hot flashes r r r Pain between shoulders r r r Poor circulation r r r Eczema r r r Irregular cycle r r r Painful tailbone r r r Heart trouble r r r Hives or allergy r r r Miscarriage r r r Stiff neck r r r Rapid heart r r r Itching r r r Painful periods r r r Spinal curvature r r r Slow heart r r r Sensitive skin r r r Vaginal discharge r r r Swollen joints r r r Stroke r r r Skin eruptions Y r N r Pregnant at this time? r r r Tremors r r r Swollen ankles r r r Twitching r r r Varicose veins Date of last papsmear:r r r Weakness

List any accidents or falls and dates: r Car r Recreation Vehicle

r Sports r School r Other

List any broken bones (fractures) or dislocations:

Ever on crutches? r No r Yes Why?

Have you ever had any spinal taps or spinal injections? r No r Yes Were you ever knocked unconscious? r No r Yes

Have you ever had a lapse of memory? r No r Yes Have you ever had X-rays taken? r No r Yes When?

For what ailments were these X-rays taken?

Do you suffer from any condition other than that for which you are now consulting us?

Are you currently taking any medication ñ prescription or over-the-counter? r No r Yes What?

I have completed this 3-page form to the best of my ability.

Signature: Date: