Nuclear Medicine Bone Scan History Form

ADVERTISEMENT

Nuclear Medicine Bone Scan
History Form
Exam date ________________________
Patient name _________________________________________ DOB _____________  Female  Male
1. Do you have pain anywhere?  Y
 N
If yes, where and for how long have you had this pain:
_____________________________________________________________________________________
2. Any known injury to the above area(s)?  Y
 N
If yes, describe:
_____________________________________________________________________________________
3. Do you have arthritis?  Y
 N
If yes, where and when was it diagnosed:
_____________________________________________________________________________________
4. Do you have a history of previously broken bones?  Y
 N
If yes, which bones and when:
_____________________________________________________________________________________
5. Did you have any surgery?  Y
 N
If yes, list surgeries:
___________________________________________ ________________________________________
___________________________________________ ________________________________________
___________________________________________ ________________________________________
6. Do you have any type of cancer?  Y
 N
If yes, where and when was it diagnosed:
_____________________________________________________________________________________
Did you have any chemotherapy?  Y
 N
Did you have any radiation treatments?  Y
 N
7. Have you had any previous x-rays, CT or MRI scans?  Y
 N
If yes, where and when:
_____________________________________________________________________________________
8. Have you ever had a previous Bone Scan?  Y
 N
If yes, where and when
_____________________________________________________________________________________
9. Do you have Diabetes?  Y
 N
FOR OFFICE USE ONLY
DOSE: __________________________________
TECH: __________________________________
INJ. SITE. _______________________________
LMP: ___________________________________
Comments _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Life
Go