Appointments
Services / Modalities
Contact Us
Physican Portal
Patient Portal
Attorney

Menu

Appointments
Services / Modalities
Contact Us
Physican Portal
Patient Portal
Attorney

Appointments
Services / Modalities
Contact Us

Menu

Appointments
Services / Modalities
Contact Us

Physican Portal
Patient Portal
Attorney Portal

Menu

Physican Portal
Patient Portal
Attorney Portal

Breast Imaging Patient Information

"*" indicates required fields

07/27/2024

Name*

First Last

Email*

MRN*

Age*

Weight

Referring Physician

Sex*

Male

Female

PATIENT HISTORY

Have you had a mammogram before?

Yes

No

When and where?

Have you had any other breast imaging?

Yes

No

When and where?

Are you having any of the following problems? (Check all that apply)

None (Check one or both)

None (Positions)*

Left

Right

Lump

Lump – L/R*

Left

Right

How long

Nipple discharge

Nipple Discharge – L/R*

Left

Right

How long? Color?

Pain

Pain – L/R*

Left

Right

How long?

Breast implant problem

Breast implant problems – L/R*

Left

Right

Describe

Nipple inversion

Nipple inversion – L/R*

Left

Right

Nipple inversion – Always/New*

Always

New

Other

Nipple inversion – L/R*

Left

Right

Describe below*

Do you have breast implants?

Yes

No

Breast implants – L/R*

Left

Right

Have you ever been diagnosed with breast cancer?

Yes

No

Breast cancer- L/R*

Left

Right

Have you ever had breast surgery (biopsy, reduction / lift)?

Yes

No

When?

Breast cancer- L/R*

Left

Right

Are you pregnant now?

Yes

No

Are you taking hormone medication?

Yes

No

How long?

What type?

Do you have a family history of breast cancer?

Yes

No

Mother

Age

Diagnosis

Sister

Age

Diagnosis

Daughter

Age

Diagnosis

It is important that I continue monthly breast self-exams according to the American Cancer Society guidelines. I also realize that a visit to my physician for a physical examination of my breasts is an important part of my routine breast screening check-up.

OUR FACILITIES

PALM HARBOR MRI
32615 US HWY 19 North
Palm Harbor, FL 34684

727.787.6900 P | 727.787.1892 F

Monday – Friday: 7 am to 10 pm
Saturday – Sunday: 8 am to 7 pm (MRI only)

HIGHLAND MRI
2946 Lakeland Highlands Road
Lakeland, FL 33803

863.510.5944 P | 863.510.5939 F

Monday, Wednesday, Thursday:
7 am to 8 pm
Tuesday: 7 am to 7 pm
Friday: 7 am to 6 pm

WINTER HAVEN MRI
409 East Central Avenue
Winter Haven, FL 33880

863.294.0999 P | 863.294.0010 F

Monday – Friday: 7 am to 10 pm

BRANDON MRI
403 South Kings Avenue
Suite 200
Brandon, FL 33511

813.210.8995 P | 813.409.2914 F

Monday – Friday: 8 am to 5 pm
Extended Hours Available Upon Request

SARASOTA MRI
2 North Tuttle Avenue
Sarasota, FL 34237

941.951.1888 P | 941.951.1910 F

Monday – Friday: 7 am to 10 pm

BRADENTON MRI
5817 21st Avenue West
Suite B
Bradenton, FL 34209

941.567.4039 P | 941.567.4041 F

Monday – Friday: 8 am to 5 pm

VENICE MRI
1370 East Venice Avenue
Suite 101
Venice, FL 34285

941.484.6500 P | 941.484.6556 F

Monday – Friday: 8 am to 5 pm

VENICE MRI - Port Charlotte
21186 Olean Blvd.
Port Charlotte, FL 33952

941.289.0705 P | 941.237.5903 F

Monday – Friday: 8 am to 5 pm

Main Office:
PALM HARBOR MRI
32615 US Hwy 19 North
Palm Harbor, FL 34684
Phone: 727.787.6900
Fax: 727.216.4789

FACILITIES

Palm Harbor MRI
Highland MRI (Lakeland)
Winter Haven MRI
Brandon MRI
Sarasota MRI
Brandenton MRI
Venice MRI
Venice MRI-Port Charlotte

MODALITIES

Staff Resources

PATIENT HISTORY

Are you having any of the following problems? (Check all that apply)

FACILITIES

MODALITIES

QUICK LINKS