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We are requesting the following information to best support you. These questions were developed with consultation from National LGBT Cancer Network, with research by The American College of Radiology, and the National Academies of Sciences, Engineering, and Medicine.
Preferred name
Pronouns
Legal name (applicable for medical records and insurance)
Date of birth
Phone number
Email
Home zip code
Preferred communication method Phone callEmail
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Health Insurance Plan (If you do not have insurance, please state none):
Health Insurance Member ID (If you do not have insurance, please state none):
Do you have a referral for a mammogram? YesNo
Estimated date of last mammogram. If you haven't had one, please state none.
Primary Care Doctor's Name (If you do not have a primary care doctor, please state none):
Primary Care Doctor's Phone Number (If you do not have a primary care doctor, please state none):
Appointment location preference Sutter Health Imaging SacramentoSutter Health Imaging RosevilleEither
I give permission to Albie Aware to disclose my information to Sutter Health for the purpose of getting a screening mammogram.* YesNo, please contact me
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Do you have any current symptoms or personal history of breast cancer? YesNo
Have you noticed any of the following? New lump in the breast or underarmThickening or swelling in part of the breastIrritation or dimpling of breast skinRedness or flaky skin in the nipple area or breastPulling in of the nipple or pain in the nipple areaNipple discharge other than milk, including bloodAny change in the shape or size of breastPain in any area of the breastNone of the above
The American College of Radiology has transgender breast/chest cancer screening guidelines. We are asking for the following information so we can provide you with these guidelines. Which of the following best represents how you think of yourself? Lesbian or gayStraight, that is, not gay or lesbianBisexualTwo-SpiritOther, I use a different termDon't knowPrefer not to answer
The National Academies of Sciences, Engineering, and Medicine recommends the following questions. What sex were you assigned at birth, on your original birth certificate? FemaleMaleDon't knowPrefer not to answer
Which of the following options best represents your gender identity? Check all that apply. WomanManTransgenderNon-binaryAgenderPrefer to self-describePrefer not to answer
Have you ever been diagnosed by a medical doctor or other health professional with an intersex condition or a difference of sex development (DSD) or were you born with (or developed naturally in puberty) genitals, reproductive organs, or chromosomal patterns that do not fit standard definitions of male or female? YesNoDon't knowPrefer not to answer
Were you born with a variation in your physical sex characteristics? (This is sometimes called being intersex or having a difference in sex development, or DSD.) YesNoDon't knowPrefer not to answer
Have you ever been diagnosed by a medical doctor with an intersex condition or a difference of sex development? YesNoDon't knowPrefer not to answer
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