Mobile Mammography Appointment Registration
Accuracy Agreement
Step 1: Screening Questions
Step 2: Personal & Work Information
Step 3: Appointment Time
Step 4: Insurance Information
Step 5: Reasons for Exam & Risk Factors
Step 6: History of Breast Procedures
Review & Sign
Step 1: Screening Questions
What is your current age?
Please Select...
Under 18
18-34
35-39
40-64
65 or above
Are you currently having any of the following problems? (Check all that apply)
bloody discharge
image detected calcifications
large nodes under my arm
nipple problem
other skin changes to breast
image detected mass (that is new)
skin thickening or retraction on clinical examination
other lump or thickening
palpable abnormality or lump
Do you have a personal history of
BREAST
cancer?
Yes
No
Information provided is subject to
HIPAA Privacy standards
.
