Rayson Radiology Center

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PATIENTS NAME:

Date:

DOB:

Age:

SEX:

DIAGNOSIS (Why are you having this study?)

PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)

Chest Pain

Angina

Shortness of breath

Coronary artery disease

Fatigue

Congestive heart failure

Stroke/TIA

Lightheadedness

High blood pressure (hypertension)

What is your blood pressure?

How long have you had hypertension?

Are you taking blood pressure medications?

Yes

If yes, list your medications:

Smoking

How many packs per day?

How many years have you smoked?

Diabetes

Coronary angioplasty (If so, please describe)

	Heart surgery? (If so, please describe)

	Vascular surgery? (If so, please describe)

	Other medical conditions?

PRIOR STUDIES AND INTERVENTION:

Prior MRI (when?)

(Where?)

Angiogram (when?)

(Where?)

Echocardiogram (when?)

(Where?)

CT (CAT) Scan (when?)

(Where?)

Stress test (when?)

(Where?)

Nuclear medicine scan (when?)

(Where?)