CT SCAN QUESTIONNAIRE

Chest - Abdomen - Head / Neck
 

Click here to print this page

*Fill out before printing

No information is transmitted
or retained with this form.

Close Window
 

PATIENTS NAME:

Date:

DOB:

Age:

SEX:

M

F

Doctor:

What complaints or symptoms lead you to seek medical attention?:

  

How long have you had these symptoms?:

Have the symptoms changed?:

Yes

No

Are you being treated for any other medical problems?  If so, please list:

Are you currently taking any medications?

 Yes No If so, please list:

Please indicate allergies:

Have you had anything to eat or drink in the last three (3) hours?

 Yes No

Any chance of pregnancy?

Yes

No

 N/A

Are you currently breast feeding?

 Yes No

Important, please answer:

Do you have an allergy to shellfish?

 Yes No

Do you have heart disease?

 Yes No

Do you have kidney disease?

 Yes No

Do you have asthma?

 Yes No

Do you have diabetes?

 Yes No      
Have you ever had surgery? Yes No If so, please list:    

Have you had previous CT Scan(s)?

 Yes No

What Type?

Abdomen

Chest

Other (Specify):

Where?

When?

Do you know the interpretation or diagnosis?

 Yes No

Diagnosis:

Have you had an x-ray that required an iodine contrast injection into a vein?

 Yes No

If yes, did you have any reaction to this injection?

 Yes No

Have you ever received radiation treatment?

 Yes No

or chemotherapy?

 Yes No

STAFF USE ONLY:

Reasons for non-ionic use:

Comments:

Previous reactions

Asthma

Allergic History

Cardiac Dysfunction

Sickle Cell

Severe Debilitation
Click here to print this page