Ct Patient Information And Assessment-Munson Healthcare Form

ADVERTISEMENT

Form # 6425 (03/15)
CT PATIENT INFORMATION AND
ASSESSMENT FORM
6425
Patient Legal Last Name:
Patient First Name:
___________________________________________
_____________________________
Middle Initial:
Date of Birth:
Age:
Weight:
_______________
_______/_______/__________
______________
__________________ lbs.
Why did your doctor order this CAT Scan? Describe type of pain and location
(i.e. right, left, or both):
Is this CAT SCAN the result of an accident or injury?
Yes
No
If yes, explain:
____________________________________________________________________________________________________________
Date of accident/injury:
___________________________________
Type of accident/injury:
_____________________________________________________________________________________________________
If motor vehicle accident, were you the driver?
Yes
No Were you restrained?
Yes
No
What speed were you going at the time of the accident?
__________________________/mph
Location of accident/injury:
________________________________________________________________________________________________
Any previous treatments for accident/injury?
Yes
No
Have you ever had any prior surgeries to the area being scanned?
Yes
No
If yes, list surgeries:
___________________________________________________________________________________________________
Have you ever had x-rays or procedures using contrast?
Yes
No
If yes, list exam(s):
______________________________________________________________________________________________________
Are you allergic to x-ray dye, CT contrast, latex, or adhesives?
Yes
No
Describe reaction:
______________________________________________________________________________________________________
Have you received a steroid prep for your exam today?
Yes
No
Do you have a history of:
Asthma
Diabetes
Kidney Disease
Heart Disease
kidney transplant or solitary kidney
Multiple Myeloma
Hypertension
Have you ever been treated or diagnosed with any kind of cancer?
Yes
No
If yes, what kind of cancer?
___________________________________________________________________________________________
Have you ever had Chemotherapy?
Yes
No
Have you ever had Radiation Therapy?
Yes
No
______________________________________________________
_________________________________
Patient Signature
Date
Time
Patient iD LabeL
______________________________________________________
_________________________________
Technologist / RN Signature (if required)
Date
Time

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Information And Referral Form Patient Information And Referral Form Medical
Patient Information And History Form Patient Information And History Form Medical
Patient Information And Medical History Form Patient Information And Medical History Form Medical
Patient Information And Medical History Patient Information And Medical History Medical
Information And Instructions For Completing Form De 3hwx - Annual Payroll Tax Return For Employer Of Household Workers Information And Instructions For Completing Form De 3hwx - Annual Payroll Tax Return For Employer Of Household Workers Financial
Cub Scout Information And Medical Care Permission Form Cub Scout Information And Medical Care Permission Form Business
Dental Implant And Patient Information And Consent Form Dental Implant And Patient Information And Consent Form Legal
Pediatric Dentistry Of North Texas Patient Information And Health History Form Pediatric Dentistry Of North Texas Patient Information And Health History Form Medical
Client Information And Consent For Waxing Form - A New You Day Spa Client Information And Consent For Waxing Form - A New You Day Spa Legal
Cadet Permission, Health Information And Privacy Act Statement Form Cadet Permission, Health Information And Privacy Act Statement Form Legal

Related Categories

Parent category: Medical
Download
Go