COMPARISON STUDIES: - PET Imaging of Oklahoma City
Reason for today’s PET scan: __________________________________________ When were you diagnosed? _______________________If cancer: Type: _______________ Location: __________________Have you received any treatment for your cancer/condition? Y FORMCHECKBOX / N FORMCHECKBOX THERAPYHave you had:Date Last ReceivedDate of Next TreatmentDate ENTIRE Course CompletedSYSTEMIC THERAPY (chemotherapy, hormonal therapy, Rituxan, interferon, etc.): Y FORMCHECKBOX N FORMCHECKBOX RADIATION THERAPY Y FORMCHECKBOX N FORMCHECKBOX OTHER (ex. ablation, bone marrow transplant, etc.): Y FORMCHECKBOX N FORMCHECKBOX Have you had any injections to stimulate your bone-marrow to produce more blood cells? (Neupogen, Procrit, Neulasta, Aranesp, etc.) Y FORMCHECKBOX / N FORMCHECKBOX If yes, when was your last injection? ____________________________ SURGICAL HISTORY:Date PerformedWhat type of procedureWhat area of the bodyRELATING TO YOUR CANCERBIOPSYPORT-A-CATH PLACEMENTOTHER SURGERIESCOMPARISON STUDIES:DATEBODY PARTFACILITYPETCTMRIBONE SCANX-RAYOTHER?SELECT THE FOLLOWING IF IT APPLIES TO YOU: FORMCHECKBOX Previous broken bones : FORMCHECKBOX Active Hemorrhoids FORMCHECKBOX Ulcers/GI disease FORMCHECKBOX GE reflux/heartburn FORMCHECKBOX Arthritis: FORMCHECKBOX Feeding or PEG Tube FORMCHECKBOX Colostomy bag FORMCHECKBOX Urine Collection Bag FORMCHECKBOX Other metal in the body: FORMCHECKBOX Pacemaker FORMCHECKBOX Smoker For how many years? FORMCHECKBOX Recent Infections: FORMCHECKBOX On oxygen FORMCHECKBOX Use a wheelchair or walkerAre you diabetic? Y FORMCHECKBOX N FORMCHECKBOX If YES, Last blood sugar: _____ Controlled by (Check one): Diet FORMCHECKBOX Pills FORMCHECKBOX Insulin FORMCHECKBOX ? List current medications you are taking: _________________________________________________________________________________________________________________________FEMALES:Are you pregnant? Y FORMCHECKBOX N FORMCHECKBOX If you are not sure, contact the technologist immediately!?Are you breastfeeding? Y FORMCHECKBOX N FORMCHECKBOX When was your last menstrual cycle? _________________________?MALES:Any history of prostate problem? Y FORMCHECKBOX N FORMCHECKBOX Describe: ________________________________________________?Do you have any trouble lying on your back with your arms over your head for about 30 minutes? Y FORMCHECKBOX N FORMCHECKBOX ?* Are you claustrophobic? Y FORMCHECKBOX N FORMCHECKBOX If you are, has your doctor prescribed any medication for you to help relax you? Y FORMCHECKBOX N FORMCHECKBOX If Yes to above, do you have a driver to take you to and from the Center after you take your relaxation medication? Y FORMCHECKBOX N FORMCHECKBOX When did you eat last? __:__ AM FORMCHECKBOX / PM FORMCHECKBOX What did you eat / drink (other than water)? __________________________________When is your follow-up appointment with your doctor? _______________________________Are there any other doctors you would like to send your PET scan to? (ex. Cancer Doctor, Radiation Doctor, Surgeon, Primary Care Doctor, Other, etc.) _______________________________________________________________________________________________________________________________________________ ______________________________________ __________________Patient PRINTED NAME Patient Signature Date ___________________________@_____________________________ Patient Email Address ................
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