Medical Diagnostic Imaging Franklin, Wisconsin | Premier ...



CT HISTORY QUESTIONNAIRETHIS SECTION TO BE COMPLETED BY PATIENTNAME: FORMTEXT DOB: FORMTEXT ?????HEIGHT: FORMTEXT ?????WEIGHT: FORMTEXT ???Have you ever had surgery of any kind? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please list them ALL: FORMTEXT Have you ever been diagnosed with cancer? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT Are you pregnant or possibly pregnant? FORMCHECKBOX Yes FORMCHECKBOX No Date of last menstrual cycle: FORMTEXT ?????Do you have any other allergies to food, medicine, etc? If yes, please explain: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any of the following:Kidney disease or renal failure FORMCHECKBOX Yes FORMCHECKBOX No SAME DAY iSTAT RESULTSLEAVE THIS AREA BLANKSPACE USED BY TECHNOLOGISTDiabetes FORMCHECKBOX Yes FORMCHECKBOX No Sickle Cell anemia FORMCHECKBOX Yes FORMCHECKBOX No High blood pressure FORMCHECKBOX Yes FORMCHECKBOX No Pheochromocytoma (adrenal gland tumor) FORMCHECKBOX Yes FORMCHECKBOX No Multiple myeloma (tumor in bone marrow) FORMCHECKBOX Yes FORMCHECKBOX No FOR CONTRAST EXAMS ONLYAs part of your exam, your doctor or radiologist may deem it advisable to administer an intravenous injection of a contrast agent to more accurately diagnose your condition. NPO Status (last time you ate or drank): FORMTEXT ?????Have you ever had a previous allergic reaction to contrast or “dye” injected for a CT Scan or cardiac catheterization? FORMCHECKBOX Yes FORMCHECKBOX No Prior to receiving IV contrast, ALL patients over age 40 require a creatinine level taken within the last 30 days. Have you had blood drawn at an outside facility within the last 30 days?If yes, where: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No Patient or Guardian Signature: _______________________________________Date:_____________________________THIS SECTION IS TO BE COMPLETED BY CT TECHNOLOGIST:Why did the doctor order the CT scan? FORMTEXT ?????How long has this been going on? FORMTEXT ?????Any recent accidents or injuries? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please explain: FORMTEXT ?????Have you had any other tests of the same area? FORMCHECKBOX X-Ray FORMCHECKBOX US FORMCHECKBOX MRI FORMCHECKBOX CT FORMCHECKBOX Other: FORMTEXT ?????If yes to one of the above, where/when? FORMTEXT ?????MDI Technologist Signature: __________________________________________Date: _____________________________6/26/18 ................
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