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CHEST CT Patient
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CHEST CT Patient
Patient Name
*
Date of Birth
Gender
*
Male
Female
Referring Physician(s)
Exam Date
Chief complaint(shortness of breathe, blood in sputum, fever, etc.)
Please list all medications you are currently taking(especially new medications over the last 6 months)
History of asthma? if yes, please explain.
Yes
No
Please Explain
*
Smoker
*
Yes
No
Ex-smoker? if yes, date stopped
Yes
No
Date Stopped
*
HISTORY OF CANCER
Personal history of cancer? if yes, what area/type?
Yes
No
What area/ type?
*
Family history of cancer? if yes, what area/type and what family member?
Yes
No
What area/ type and what family member?
*
ECPOSURE HISTORY
Pets ( cats, dogs, any newly acquired pets)
Yes
No
Any newly acquired pets
Farmers/ gardener
Yes
No
Explain
Work history(prior exposure to asbestos, work in a mine, textile manufacturing, constructionr?
Yes
No
Work History
New Job, recent change in work environment
Yes
No
Change in work environment
History of Sarcoid?
Yes
No
History of Lupus?
Yes
No
History of Rheumatoid Arthritis?
Yes
No
History of any connective tissue disorder?
Yes
No
History of pulmonary embolism ?
Yes
No
History of deep venous thrombus in the legs ?
Yes
No
Are you immunocompromised?
Yes
No
Have you ever lived in the Midwest or Southwest United State?
Yes
No
History of recent travel outside the U.S? If yes, where?
Yes
No
If yes, where?
Patient Signature
Date
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