Patient Information Form - Rolling Oaks Radiology Page 2
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2MEDICAL INFORMATION
Is this visit related to an auto accident?
Yes
No
Is this visit related to an injury sustained while at work?
Yes
No
Date of Injury:
___________/___________/___________
Height: ___________ ft. ___________ in.
Weight: ___________
SMOKING STATUS:
Current Every Day
Current Some Days
Never smoked
Smoker, current status unknown
Former smoker
Unknown
ACTIVE MEDICATIONS:
None
ActoPlus Med
Fortamet
Glyburid Met
Metaglip
Avandamet
Glucophage
Glycomet
Metformin
Diabex
Glucovance
Janumet
PrandiMet
Diafomin
Glumetza
Kombiglzexr
Riomet (liquid form of Metformin)
MEDICAL HISTORY:
None
Aneurysm Clip / Coil
Breast Implants
Insulin Pump
Parplegic
Aneurysm Had Surgery
Cancer
Metal In the Body
Previous CT Contrast Reaction
Aneurysm NO Surgery
Diabetes
Morphine Pump
Previous MR Contrast Reaction
Asthma
Hypertension
Pacemaker
Renal Disease
ALLERGIES:
None
Adhesive Tape
Mild
Moderate
Severe
Latex
Mild
Moderate
Severe
Bee Sting
Mild
Moderate
Severe
Lidocaine / Novacaine
Mild
Moderate
Severe
Betadine (Topical Iodine)
Mild
Moderate
Severe
Mold
Mild
Moderate
Severe
Contrast (Med. Imaging)
Mild
Moderate
Severe
Peanut or other nut
Mild
Moderate
Severe
Dog, Cat, or Animal
Mild
Moderate
Severe
Penicillin
Mild
Moderate
Severe
Dust
Mild
Moderate
Severe
Rubbing Alcohol
Mild
Moderate
Severe
Fruit
Mild
Moderate
Severe
Shellfish
Mild
Moderate
Severe
Grass / Pollen
Mild
Moderate
Severe
Sulfa Drug
Mild
Moderate
Severe
Mild allergic reactions include hives, itching, nasal congestion, rash and watery eyes.
Moderate allergic reactions include cramps, chest tightness, diarrhea, difficulty breathing, difficulty swallowing, dizziness, light headedness, flushing/redness
of face, nausea, vomitting, palpitations, swelling of face/eyes/tongue, wheezing, weakness, and unconciousness.
Severe allergic reaction is anaphalytic shock.
TO OUR FEMALE PATIENTS
Some imaging procedures are contra-indicated (not recommended) for patients who may be pregnant. If you may be pregnant, please notify one of our team
members. By my signature below, I acknowledge that I have read and understand this statement and state that I am not pregnant and there is no chance that I
may be pregnant.
Signature
Date
Date of Last Menstrual Period: _________/________/________
AUTHORIZATION & AGREEMENT
I hereby authorize and direct my insurance carrier to pay directly to this provider of medical services any benefits due under my
insurance plan. I agree to pay the balance of charges not paid under my plan. I also hereby authorize this provider to use, disclose
or obtain any of my personal health information for treatment and payment. If I am UNINSURED, I understand I am fully responsible
for all charges.
Signature of Patient, or Personal Representative
Date
Patient:
DOB:
MRN:
Date of Service:
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