Clinical Information General/chest X-Ray Form
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1CLINICAL INFORMATION
GENERAL/CHEST X-RAY
XH
ACCT # ____________________
Tech’s Init./Exam Date _________________
Referring
Patient’s Name ________________________________
___________________________________
Physician
Next Appointment
Date of Birth_________________ Age________
with Referring Physicians _________________________
TYPE OF EXAM
PA Chest
Complete Chest
Abdominal, Flat
Abdomen, Flat and Upright
Skull
Sinus
Ribs
C-Spine
L-S Spine
T-Spine
Extremity (area) __________________________________________________________
Other __________________________________________________________________
Why are you having this examination (medical problem) including symptoms? __________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List other imaging studies you have had regarding this problem and where they were performed (if applicable):
CT ______________________
X-ray ________________________
Ultrasound______________________
________________________
MRI ____________________
Nuclear Medicine/PET ___________
Other
What were the results? ____________________________________________________________________
Did you bring a copy of the results and films? _________________________________________________
History and dates of prior surgeries of this area: ______________________________________________
______________________________________________________________________________________
Do you have a personal or family history of cancer?
Yes
No
If yes, please explain. _____________________________________________________________________
CHILDBEARING WOMEN ONLY Date of last menstrual period___________________
Are you possibly pregnant?
Yes
No Patient’s
(If yes, notify technologist immediately)
Signature______________________________ Date___________
FOR CHEST X-RAY PATIENTS ONLY
Please check any of the following symptoms you may be experiencing:
Cough
Wheezing
Chest Pain
Shortness of Breath
No Symptoms
Other __________________________________________________________________________________
Comments: _____________________________________________________________________________
______________________________________________________________________________________
Have you had a previous chest x-ray?
Yes
No
If yes, when?__________________ Where? ______________________________________________________
Please circle appropriate answer:
Smoker
Ex-Smoker
Non-Smoker
YOUR INSURANCE COMPANY MAY OR MAY NOT REIMBURSE FOR ROUTINE X-RAYS.
I understand that I am responsible for full payment if my insurance company does not pay.
Patient’s Signature
Date
OF-CHESXR 313
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