Breast Imaging Patient Questionnaire

First Name *

Last Name *

Your date of birth *

Email Address *

Have you had a mammogram before? *

YesNo

Where did you have this previous scan? *

When did you have this previous scan? *

Are you or could you be pregnant? *

YesNo

Are you taking Hormone Replacement Therapy (HRT) /Thyroxin/Oral Contraceptive? *

YesNo

Do you have breast implants? *

YesNo

Have you had any other surgery or procedures to your breasts previously? *

YesNo

Please provide details: *

Do you have any family history of breast cancer? *

YesNo

Relationship to you and approx. age: *

Do you have a breast lump? *

YesNo

Do you have any other breast issues? (eg pain or skin changes) *

YesNo

Provide details *

Have you had your risk of breast cancer assessed? *

YesNo

(This can help determine whether you are at high or low risk of developing breast cancer)

Some people have a higher breast cancer risk than others, and this can change the guidelines for your screening. We offer consultations with our breast imaging specialist, who reviews your breast imaging from today and then conducts an assessment to determine your risk of developing breast cancer as well as recommendations to ensure your breast imaging is tailored appropriately.

Breast cancer screening can be tailored accordingly if you are classed as high or low risk, for example, a breast MRI might be a good additional screening tool for high-risk patients.

Would you like to book a breast cancer assessment? (please be aware these consultations have a $100 fee with no Medicare rebate) *

YesNo

Today's date *