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CT Questionaire

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CT Questionaire

COMPUTED TOMOGRAPHY (CT) CLINICAL INFORMATION

Patient Name *

Body Part to be Scanned *

Gender *MaleFemale

Exam Date *

Reason for exam *

Please list all medications you are currently taking

Have you had previously related studies(nuclear scan, x-ray, ultrasound. CT, MRI or PET)? if yes, please explain and bring studies to your appointment *YesNo

Type of exam

Where ?

When ?

Results

Have you had any surgery or therapy? if yes, explain type and whenyesNo

When?

For female patients only: Date of last menstrual period

Are you Nursing ? *yesNo

Are you Possibly pregnant? If yes notify the technologist immediately *yesNo

Patient Signature *

Date *

Contrast Questionnaire: Have you had, or do you have any of the following?

Previous reaction to contrast (If yes, notify RN immediately.)YesNo

AllergiesYesNo

Infectious diseasesYesNo

History of heart disease (arrhythmia, congestive , heart failure ,angina, myocardial infarction)YesNo

HypertensionYesNo

AsthmaYesNo

Diabetes mellitusYesNo

Multiple myelomaYesNo

PheochromocytomaYesNo

Sickle cell diseaseYesNo

Renal failureYesNo

SmokerYesNo

Non-smokerYesNo

Ex-smokerYesNo

Interleukin 2 (received within the last 2 weeks)YesNo

Interleukin 2 (expect to receive treatment today or tomorrow)YesNo

If yes to any of the above please explain *

Technologist/RN:

Date

CHEST CT PATIENT QUESTIONNAIRE

Patient Name *

Date of Birth *

Gender *MaleFemale

Referring Physicians *

Exam Date *

Chief complaint (shortness of breath, blood in sputum, fever, etc.)

Please list all medications you are currently taking *

History of asthma? *YesNo

If yes, please explain

Smoker *YesNo

Ex Smoker *YesNo

If yes, date stopped

HISTORY OF CANCER

Personal history of cancer? *NoYes

If yes, what area / type ?

Family history of cancer? *YesNo

If yes, what area / type and what family member ?

EXPOSURE HISTORY

Pets (cats, dogs, birds, any newly acquired pets) *YesNo

Farmer / Gardener *YesNo

Work history (prior exposure to asbestos, work in a mine, textile manufacturing, construction) *YesNo

New job, recent change in work environment *YesNo

History of Sarcoid? *YesNo

History of Lupus? *YesNo

History of Rheumatoid Arthritis? *YesNo

History of anv connective tissue disorder? *YesNo

History of deep venous thrombus in the legs? *YesNo

Have you ever lived in the Midwest or Southwest United States? *YesNo

History of recent travel outside the U.S.? *YesNo

If yes, where?

Patient Signature *

Date *

Please do not fill in this field.

Contact Us

516 Hamburg Turnpike, Suite 6, Wayne, New Jersey 07470
info@wayneradiology.com
(973) 720-0050
Fax: 888.455.2577

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