This patient intake form MUST be completed 24 hours prior to your scheduled exam.

This form is NOT set up for mobile completion, please complete on a computer.

If you have any questions regarding this form, or if your appointment is less than 24 hours away please contact us at 605-681-6884.

Mandatory Protocols for Thermal Imaging

 

Patient Preparation:

Thermal imaging is a heat sensitive test. Anything which creates heat should be avoided prior to testing. Excessive metabolic activity, friction, or any of the activities listed below which will alter heat readings.

 

1 Month Prior:

• No minor breast surgery, i.e. biopsy

• We may still perform testing after biopsy. Write this in form.

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1 Week Prior:

• Be cautious of too much sun exposure in order to avoid sunburn. Scans will have to be rescheduled if the patient has a sunburn of any sort.

 

48 Hours Prior:

• Men with beards should shave their face and neck, as well as backs

• Avoid all tanning and limit sun exposure

 

24 Hours Prior:

• Avoid chiropractic care, massage therapy or acupuncture

• No saunas, steam baths, hot tubs, heating pads, or hot water bottles

• No analgesic creams or balms

• Do not shave underarms (Should be done day prior)

• Reschedule if you experience a significant fever (100 degrees or more)

• Refrain from sexual activity

 

Day of Exam:

• Do not use creams, lotions, cosmetics, ointments, deodorant, antiperspirants, powders or any other skin product

• Please bring a hair tie and headband to remove hair from your forehead and back of neck

• Remove all piercings and jewelry prior to exam, unless unable to.

 

4 Hours Prior:

• Avoid hot showers or shaving

• Avoid physical therapy or exercise

• No coffee, tea, soda, or other beverages containing caffeine. No alcoholic beverages.

• Do not smoke cigarettes or use any product which contains nicotine

• Women- do not wear a bra for the 4 hours leading up to the exam

 

2 Hours Before the Exam:

• Avoid hot or cold liquids

• Avoid eating or chewing gum

• Avoid using a cell phone

• Avoid heated seats

• Do Not wear face coverings or masks

 

Prior to and During Exam:

• Please inform us if you have a hot flash during the session

• Try to relax prior to and during the exam. Stress will affect your exam.  

• Do not wear face coverings or masks