Windrose Digital Thermal Imaging Center - Windrose Naturopathic Clinic

Windrose Digital Thermal Imaging Center Family Practice – Preventative Care

1137 W Garland Ave, Spokane WA 99205 (509) 327-5143 (509) 327-9813 (fax)

About your upcoming thermography:

Thank you for choosing Windrose Digital Thermal Imaging Center. We are a member of the IACT,(International Academy of Clinical Thermology). Your certified thermal imaging technician is Karla Porter, RT(R) (CT) ARRT, CTT.

Your Thermal Scan is scheduled for: _____________________________________________________

_______________________ , __________________ , _______________ , at _____________ AM/PM(day) (month) (date)

Your follow-up report of the findings is scheduled for:

_______________________ , __________________ , _______________ , at _____________ AM/PM(day) (month) (date)

Please do the following immediately

1. Read the Patient Information Sheet.

2. Review the Patient Preparation Checklist. Be sure to follow these instructions. If you do not wemay not be able to perform your Thermogram and you will be rescheduled.

3. Complete the Breast Health History Form. Bring it with you, along with ANY OTHER lab reports,mammograms or hormone testing that involves your breast health.

4. Sign the Informed Consent For Digital Thermographic Imaging Form and bring this with you aswell.

Please be aware that our clinic has a NO CHEMICALS / SCENTS ZONE policy:We ask that ALL patients refrain from wearing perfumes, colognes, and / or strong hair chemicals for your visits. Many ofour patients and some of our staff suffer from Multiple Chemical Sensitivity; this condition can cause severe reactionssuch as headaches, stomach pain, and asthma attacks. We reserve the right to re-schedule your appointment if you arenot in compliance with this policy.

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PATIENT INFORMATION

Preparing for your digital thermal scan:

It is very important that you follow the recommendations on the Patient Preparation Checklist for anaccurate scan!

Procedure:

You will be required to remove all upper body clothing. You will need to acclimate your upper bodyto a 65 degree room temperature prior to the scan. After 15 minutes of acclimation, we will take aseries of thermal images. Your referring physician may ask you to do a cold challenge. You willthen submerge your hands into a pan of cold water for one minute. After a three-minute wait, asecond series of images will be taken to identify specific details of the cooling down of breast tissueand vascular patterns.

How the test will feel:

The test is very comfortable. There is no compression on the breast. This procedure is pain freeand safe. The number of people involved in the procedure will be limited to protect your privacy.The room air may feel cool on your breasts as they adjust to the room temperature before scanning.The procedure is totally non-invasive; the camera does not emit radiation of any kind.

Time before test results are available:

Results are usually available within 2 weeks.

While participation in a thermal imaging early detection program can increase your chance ofdetecting and monitoring breast disease, as with all other tests, it is still not a 100% guarantee ofdetection. Thermography is the only noninvasive imaging modality that looks at breast function andrisk assessment for developing cancer. Positive thermography findings are 10 times more importantthan a positive family history for developing cancer.

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PATIENT PREPARATION CHECKLIST

It is crucial that you follow these restrictions in order to achieve accurate results from your thermalscan.

Avoid sun exposure or tanning lights for 5 days prior to your test.

Avoid a strenuous workout, exercise or weight training for 24 hours prior to your test.

No physical therapy, EMS, TENS, ultrasound treatment, acupuncture, chiropractic, physical stimulation, hot or cold pack use for 24 hours before your exam.

Do not use lotions, powder, deodorant, antiperspirant, perfume, makeup or anything topical on the body area to be imaged the day of your exam.

If any body areas included in the images are to be shaved, this should be done the evening before the exam or at least 4 hours prior to your examination.

Allow at least 4 hours after a hot shower, hydrotherapy, hot tub or sauna.

Do not smoke or have any caffeine for 2 hours prior to your exam.

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

If not contraindicated by your doctor, avoid the use of pain medications and vasoactive drugs the day of your exam. You must consult with your doctor before changing the use of any medications.

For breast imaging, if you are nursing you should try to nurse as far from 1 hour prior to your exam as possible.

Let the technician know if you have had any recent skin lesions or blunt trauma to the area to be scanned.

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FREQUENTLY ASKED QUESTIONS

When should I start breast thermography? When possible, thermal breast imaging should beginat age 20 to establish a baseline reading. Screening should continue every three years between theages of 20 and 30. After age 30 it is suggested that women receive one screen per year.

What if I've had breast surgery, such as mastectomy or breast enhancement? No problem.Clear and accurate images can be obtained regardless of any history of breast surgery, includingmastectomy, lumpectomy, breast reduction or breast enhancement. In fact, breast thermography isthe initial screening method of choice for women who have had breast surgery of all kinds due tothe limitations of mammography.

Where is the test performed? At our dedicated thermal imaging laboratory that is specificallydesigned and climate controlled.

Who performs the test? The test is performed by a Certified Clinical Thermographer, or alicensed Doctor of Naturopathic Medicine.

Who reads my scan? We are pleased to have Dr. Robert Kane, DC, DABCT, FIACT, as ourcenter’s interpreter. Dr. Kane serves on the board of the IACT, the oldest thermographyassociation. Dr. Kane teaches doctors worldwide on the science and interpretation of thermalimaging. Dr. Kane is a Board Certified Clinical Thermologist; Diplomat, American Board of ClinicalThermology; Diplomat, American Board of Medical Infrared Imaging; Board Member InternationalAcademy of Clinical Thermography • www.iact-org.org

Are there any risks or side effects? There are no risks involved. The procedure is non-invasive.There is no radiation or pain.

How long does it take? The patient time for the procedure is approximately 45 minutes to includea clinical breast examination.

What is the cost of the test? A breast thermography is $275.00. This is due and payable at thetime of service. This cost includes professional interpretation and clinical breast examination. A 2week follow-up appointment is made for a 1 hour consultation to review your results. This includesan individualized plan for your breast health. The follow-up appointment is approximately $105.00for a typical 30 minute appointment (pro-rated accordingly if less time is needed).

When will I get my results? Results are usually conveyed within 2 weeks.

Why is Breast Thermal Imaging so important for a woman’s breast health? Breastthermography can identify changes in the breast that are likely to lead to breast disease (cancer) 4-10 years before a tumor would appear. It can also identify who’s at risk for developing cancer in thefuture and allows, for the first time, the opportunity for breast cancer prevention.

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FREQUENTLY ASKED QUESTIONS (continued)

Can breast thermography be used to diagnose breast cancer? No. A positive thermographystudy is not a diagnosis of breast cancer, nor is a positive mammogram or ultrasound a diagnosis ofbreast cancer. Rather, all of these tests indicate the likelihood that breast cancer is present. Theonly true objective means of determining breast cancer is a biopsy. Thermography = risk,mammogram = detection, biopsy = diagnosis.

Why is a Thermogram so effective? Prior to a tumor being formed, cells in the breast begin tocreate a cancer-friendly environment. Part of this process involves angiogenesis, the developmentof new blood vessels. These blood vessels provide a blood supply to the area for the cancer togrow. The process of angiogenesis creates heat patterns. Thermography, being sensitive tofluctuations in temperature, can detect these changes in the breast far earlier than other screeningmethods.

What is the purpose of putting the hands in cold water? Under normal conditions when nobreast disease is present, putting hands in cold water causes the brain to constrict blood flow to theperipheral blood vessels, including those in the breast, favoring blood flow to the major organs.When an abnormal breast process is occurring, the abnormal cells exert chemical control over theperipheral blood vessels in the breast, ensuring that blood flow to the area is not restricted. Theheat generated by these blood vessels would be evident in a thermogram.

How is thermography different from mammography? Thermography detects physiology(function). Inflammatory and small multifocal cancers are invisible to mammograms.Thermography is the only noninvasive imaging modality to detect breast function. Thermal changesin tissue can be seen as small as 1/5 of one mm (the thickness of a credit card or end of a pen).

Mammography detects anatomy (structure). For a tumor to show on a mammogram it must be atleast the size of a pea (3mm).

What are some additional uses for thermography? Musculoskeletal disorders, inflammation,chronic pain and injuries can be detected and monitored. Thermal imaging is being used to studysome cardiovascular disorders,endocrine/metabolic disorders, neurological disorders,dermatological disorders, i.e., Carpal tunnel syndrome, headaches, diabetes, myofascial irritation,neck and back problems, neoplasia, neuropathy, soft tissue injury, TMJ conditions, dental, CRPSand more.

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Last Physical Breast Examination: Date

Results: Normal Other

Mammogram: Date

Results: Normal Other

Other Breast Tests (Ultrasound, MRI or Biopsy etc.) List test, date and results

Complete all that apply:

Diagnosed with breast cancer: Date of diagnosis ,

Location of cancer and type, if known

Name: Age: Date:

Address: Email:

City: State: Zip:

Daytime Phone #: Date of Birth: Sex: F M

Describe any current breast concerns such as lumps, pain, or abnormal examination findings:

mark the area of any new ConCern on the diagram:

Initial Breast Health HistoryImaging CenterPlease print out your completed form & bring it with you to your appointment

© 2008 Robert L. Kane, DC, DABCT All rights reserved.

Lumpectomy Mastectomy Reconstruction: Date and details of procedure:

Radiation treatment: Date last performed:

Chemotherapy: Since:

Other treatment

Fibrocystic breasts Y N, Cystic breasts Y N Other breast conditions

Breast surgery other than for cancer (benign lumpectomy, implants, reductions, etc.).

Date and procedure:

Past injury to the breasts: Provide date, description and location

Birth control pills use: Duration: Currently taking: Y N

Prescription hormone replacement use including bioidentical:

Duration: Currently taking: Y N

List types:

Non-prescription hormonal cream use and/or supplements to balance female hormones or thyroid.

Currently taking: Y N

List types:

Other medications: List types:

Breast feeding: Currently Y N, Number of children nursed for over 1 month:

Pregnant: If not, current cycle day (# of days since 1st day of period)

Menopause: Experiencing symptoms of menopause or perimenopause: Y N

Age of last menses, if it has stopped:

Both (not one) ovaries removed: Y N, Age (or ages) of removal:

Family history of breast cancer: List family member(s):

Imaging Center


Consent for testing proCedure

Thermal Imaging of the breasts (otherwise known as breast thermography) measures surface temperature

and provides information which may be used to help determine current and/or future risk for breast disease.

Thermography can not diagnose breast cancer or rule out its presence. Some cancers do not produce

sufficient temperature changes at the surface of the breasts to be seen with thermography. It does not

replace mammography or any other breast examination. Thermal Imaging has no known risks or side effects

associated with its use. Initial

I authorize this clinic’s personnel to perform this thermal imaging examination and to send the images to

robert l. kane, dC, daBCt for interpretation. Initial

I have read and complied with the pre-examination instructions for proper thermal imaging. Initial

Print Name: Signature:

Date:

please do not write in this seCtion

Tech: Patient Temp: F Laboratory Temp: C

offiCe use only

Doctor in charge of your breast health:

Name:

Address:

Zip: Phone:

May we send your doctor the report? Y N

Imaging Center




FEES & FINANCIAL AGREEMENT

We practice medicine differently from the typical medical model. First of all, we take considerably more time with you. Most of our appointmentsare reserved for about an hour. This is so we can thoroughly evaluate your concerns and talk with you about your healing plan. We dedicate ourtime with you for a full understanding of your condition and concerns.

Because we operate entirely different from the typical medical office, we have found most insurance programs do not adequately compensate us forthe time we take with all our patients. Consequently, we do not bill insurance plans. Some insurance plans may reimburse you for our care. It isup to you to submit our bill to your insurance carrier if you so choose. In any event, complete payment for our services is due on the date ofyour visit.

Here is a brief example of our typical office fees:

Digital Thermal Imaging for breast cancer risk assessment. $ 275.00

Report of Digital Thermal Imaging and plan of therapy (typically 30 minutes, pro-rated if less) $ 105.00

Cancellation Policy: Patients will be billed for any appointment cancelled with less than 24 hours notice. There is a $75.00 missedappointment fee.

I understand that I am wholly and personally responsible for payment on date of service. The Windrose Naturopathic Clinic is not a participant inMedicare or insurance plans. I realize that I may request the attending physician’s statement of diagnosis and services provided to me, which I maysubmit to my insurance company for reimbursement of the treatment cost, as may be provided by my plan. The Windrose Naturopathic Clinic doesnot guarantee that I will receive reimbursement from my insurance carrier. I understand that Windrose Naturopathic Clinic, at it’s option, maycharge me interest on any unpaid balances.

I have read and agree to the financial terms and cancellation policy above:

________________ _________________________________________________ ______________________________________Date Patient Signature Social Security #

Other people I authorize to discuss my medical information

It is okay with me for you to discuss my medical information with:

Name: ___________________________________________________ Relationship: ___________________________________



________________ ___________________________________________________Date Patient Signature

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INFORMED CONSENT FOR DIGITAL THERMOGRAPHIC IMAGING

Thermography is simply a procedure utilizing digital infrared thermal imaging cameras to visualize and obtain an image of the infraredradiation (heat) coming from the surface of the skin. The thermographic procedure is performed as an aid to the diagnosis of theabnormal temperature patterns, which may or may not indicate the presence of a disease process or pathology.

The thermographic procedure is not a stand-alone diagnostic tool, but an adjunct to be used with other clinical or diagnostic findings.Thermography can not diagnose breast cancer or rule out its presence. Some cancers do not produce sufficient temperature changes at thesurface of the breasts to be seen with thermography. It does not replace mammography or any other breast examination. Thermal Imaging has noknown risks or side effects associated with its use.

This office provides only the thermographic component.

I,______________________________________________________________________, hereby authorize the doctor’s and/or staff ofThe Windrose Naturopathic Clinic to perform a procedure utilizing digital infrared thermal imaging cameras to visualize and obtain animage of the infrared radiation (heat) coming from the surface of the skin and that I will be disrobed to allow for the surfacetemperature of my body to cool to an ambient room temperature. I understand that this procedure does not use radiation and is notharmful to me.

I further authorize this clinic’s personnel to send the images to Robert L. Kane, DC, DABCT for interpretation.

The information provided will be available to my personal physician, HMO, PPO, or other health care provider for further diagnosisshould an abnormality be detected.

With this knowledge, I voluntarily consent to the above procedures and that I realize that no guarantees have been given to me by thedoctor’s or staff of The Windrose Naturopathic Clinic regarding cure or improvement of my condition. I understand that I am free towithdraw my consent and to discontinue participation in these procedures at any time.

Privacy Notice: The Windrose Naturopathic Clinic is required by law to respect your privacy by following specific HIPPA guidelines. A “Notice ofPrivacy Practices” document is available upon request.

I have read and complied with the pre-examination instructions for proper thermal imaging.

______________ ______________________________________________Date Patient Signature

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Windrose Digital Thermal Imaging Center - Windrose Naturopathic Clinic

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