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PET / CT PATIENT QUESTIONNAIRE

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Patients Name:

Date of Exam:

Date of birth:

   Age: Sex: M F

Height:

 Weight:

Referring Physician:

 Phone Number:

Have you had a PET scan before?

 Yes No

If yes, where and when?
     

Have you had a prior CT scan or MRI?

 Yes No

If yes, where and when was the most recent?
           

PATIENT HISTORY AND RISK ASSESSMENT FOR CONTRAST MEDIA:
           

Has patient had a prior x-ray study that required injection of contrast media?

 Yes No

If so, did the patient experience a reaction to the contrast media?

 Yes No
 

If yes, please specify symptoms:?

    
         

Mild Reaction:

        
  Itching Headache Nausea, vomiting Shaking  
  Rash, hives Chills Dizziness Other
           

Moderate Reaction:

        
  Generalized urticaria Severe nasal congestion Marked swelling: eyes, face
  Dyspnea Bronchospasm / Wheezing Vasovagal response
  Hypertension / Hypotension Tachycardia / Bradycardia    
           

Severe life-threatening Reaction:

      
  Laryngeal edema Profound hypotension Convulsions
  Unresponsiveness Clinically manifest arrhythmias Cardiopulm, arrest
           

Reason for this exam?
 

Prior Surgery or Biopsy?

 Yes No

If yes:

What kind of operation(s)?

When was it done?

Which body part?

What was the pathology report?

Additional:
 

Mark if you have any of the following (please specify location on your body)
 

Colostomy / ileostomy
 

Indwelling catheter
 

Drains / open wounds
 

Infections
 

Pacemaker
 

Artificial joints
 

Implants
 

Prior Chemotherapy?

 Yes No

If yes, which agents (if known)?

When did it start?

When did it finish?

If currently on chemotherapy, please indicate the date of the last cycle:

Did you receive any bone marrow stimulating drug?

 Yes No

Please specify agent (Neupogen, Epogen)

Date of last administration:
 

Prior radiation therapy?

 Yes No

If yes, which body part?

When did it start?

When did it finish?
 

Ever had any trauma, fractures or recent injuries?

 Yes No

If yes, please list with approximate date(s) and part of the body.
 

Mark if you have any of the following (please specify how long you have had this problem)
 

Heart disease
 

Hypertension / High Blood Pressure

Stroke

Lung disease
 

Lung cancer

 Asthma Bronchitis Smoker Yes No How long?

Kidney disease

Liver disease

Reflux / heartburn

Thyroid problems
 

Nodules / inflammation

 Hypothyroidism Hyperthyroidism

Thyroid problems

Hernia

Skin problems

Multiple myeloma or paraproteinemia

Sickle cell disease
 

Please list your medications, and the reason why you take them:
 

If you are Diabetic, how is your diabetes treated?
 

Pills?

 Yes No Type:
 

Insulin?

 Yes No How much?
 

Diet and exercise?

 Yes No    
 

What is your fasting blood sugar/glucose?
 

Are you having joint problems?

 Yes No

If yes, please specify which joints:

Please rate the quality of joint pain:

 Mild Moderate Intense
 

Are you having bone pain?

 Yes No

If yes, location?

Please rate the quality of bone pain:

 Mild Moderate Intense
 

Do you have any known allergies (medication, shellfish or other foods)?

 Yes No

If yes, please specify:
 

Any recent intramuscular injection in the last 2 weeks?

 Yes No

Please specify body part and if for vaccine therapy, B12 injection, etc.:
 

Describe your bowel habits on the scale below:
(Constipation) 1 2 3 4 5 6 7 8 9 10 (Diarrhea)
 

Are you pregnant?

 Yes No Last menstrual cycle:
 
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