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 _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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