Pregnancy Questionnaire And Attestation Form
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1DATE_________________________________________WITNESS____________________________________
RIA 600WEB
PREGNANCY QUESTIONNAIRE AND ATTESTATION FORM
LAST NAME: ___________________________ FIRST NAME_____ _________________________ MI:______
This informational questionnaire is designed for female patients between the ages of 12 and 50, inclusive,
who are requested to undergo radiological procedures of the abdomen, pelvis, hips and/or proximal
femur, or any MRI or Nuclear Medicine exams. These radiological exams, performed during pregnancy,
may subject the developing embryo or fetus to potentially harmful effects of ionizing radiation or strong
magnetic fields and radiofrequency energy. Radiology Imaging Associates has adopted guidelines
established by the National Council on Radiation Protection and Measurements, which recommend that x-ray
exams be performed only during the 14 days following the onset of menstruation to prevent exposure to a
developing pregnancy. Certain factors, however, may allow these exams to be performed outside of these 14
days.
In order to assess the possibility of your being pregnant, Radiology Imaging Associates asks that you provide
us with the following information prior to undergoing these procedures. We regret that these questions must
be of a very personal nature, but your truthful answers are necessary to help us determine the likelihood of
pregnancy. If you strongly object to providing this information, please let us know and we may arrange a
pregnancy test instead. Thank you.
If you can answer YES to any of the following questions that will be sufficient to exclude pregnancy:
HAVE YOU HAD A HYSTERECTOMY (UTERUS REMOVED)?
O YES
O NO
HAVE YOU HAD A TUBAL LIGATION (BOTH TUBES TIED)?
O YES
O NO
HAVE YOU HAD BOTH OVARIES SURGICALLY REMOVED?
O YES
O NO
ARE YOU PRESENTLY TAKING BIRTH CONTROL PILLS?
O YES
O NO
ARE YOU USING THE NORPLANT IMPLANT FOR BIRTH CONTROL?
O YES
O NO
ARE YOU USING THE ORTHO-EVRA PATCH FOR BIRTH CONTROL?
O YES
O NO
HAVE YOU HAD THE DEPO-PROVERA INJECTION IN LAST 90 DAYS?
O YES
O NO
HAVE YOU REACHED MENOPAUSE?
O YES
O NO
If you answered NO to all of the above:
ON WHAT DATE DID YOUR MOST RECENT MENSTRUAL PERIOD BEGIN? __________________
WAS IT OF NORMAL DURATION AND FLOW?
O YES
O NO
PLEASE INFORM US OF ANY OTHER REASON WHY YOU COULD NOT BE PREGNANT.
REASON: _____________________________________________________________________________
This form will be printed at the time of your visit for your signature indicating you have provided the
above information willingly and to the best of your knowledge.
_______________________________________________
__________________________
Signature of Patient/Legal Guardian
Date
_______________________________________________
Witness
RIA 702WEB
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