McLaren Health Care
Mammography Next Step Form

Please answer the following questions so we can determine which mammography service will best meet your needs.

Were you born Male: *

Yes

No

Have you recently experienced any breast pain, tenderness, lumps or nipple discharge?: *

Yes

No

Do you have a personal history of breast cancer or is this a follow up to an abnormal mammography exam?: *

Yes

No

Do you require the use of a translator and/or do you require any special assistance (use of a wheelchair, help standing, etc.)?: *

Yes

No

Are you pregnant?: *

Yes

No

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