Ct Patient Screening Form printable pdf download

CT Patient Screening Form - Part A

Patient Label or Accession Number

Factors such as weight, body habitus and scan type may

determine if scan can be performed.

Patient: Please complete all the information contained in this boxed area.

Patient Name (Last, First): ________________________________________________

Date of Birth: ______________

Patient Address: _______________________________________________________

Date of Exam: _____________

City, State, Zip: ___________________________________________ Patient Stated Weight: _____

Height: _____

lbs/kgs

Please list previous surgeries and their dates:

_____________________________________________________________

________________________________________________________________________________________________________

PATIENT HISTORY

** Pregnant ...................................................................q Yes

q No

History of Cancer..........................................q Yes

q No

* Personal history of Diabetes....................................q Yes

q No

What Type ____________________________________

* Allergies to IV dye or latex .......................................q Yes

q No

Chemotherapy ______

Radiation ______

* Breast Feeding ..........................................................q Yes

q No

Previous Stroke ............................................q Yes

q No

* Multiple Myeloma ....................................................... q Yes

q No

Metallic Implant/Prosthesis ......................... q Yes

q No

* Sickle Cell Anemia ...................................................q Yes

q No

Orthopedic Devices ................................... q Yes

q No

* Pacemaker ................................................................q Yes

q No

Surgical Clips................................................q Yes

q No

* Infusion Pump ..........................................................q Yes

q No

Epilepsy (Seizures)....................................... q Yes

q No

* Neurostimulator .......................................................q Yes

q No

Uncooperative or Disoriented ..................... q Yes

q No

* Implanted or External Medical Devices ..................q Yes

q No

Claustrophobia .............................................q Yes

q No

Asthma/COPD/Emphysema ......................................q Yes

q No

Unable to Hold Still ....................................... q Yes

q No

History of High Blood Pressure ..............................q Yes

q No

Difficulty Swallowing .................................... q Yes

q No

If yes, is it now controlled with medication? .....q Yes

q No

Removable Dental Work .............................. q Yes

Irregular Heartbeat ....................................................q Yes

q No

Braces............................................................q Yes

History of recent diarrhea in past 2-3 days .............q Yes

q No

History of Falls within the past 30 days ..................q Yes

q No If yes, most recent fall date:

Any previous imaging study related to the reason for today’s exam? ............................................................................

q Yes q No

Type of Exam

Facility

Date

I understand the risk of having an x-ray while pregnant and I do not believe I am pregnant. Initial:

Date:

Signature of Patient:

Date:

Time:

(Parent or Guardian if patient is a Minor or Incapacitated)

Relationship:

Single asterisk (*) items may require further discussion between technologist and radiologist.

(**) Pregnancy requires signed informed consent. Document any verbal approvals on Part B.

Medical Record # / Accession #: _______________________

Facility Name: ___________________________________

Exam Ordered - CT of: _______________________________

Referring Physician/Specialty: _______________________

Diagnosis: ______________________________________

CTDI

_____________ mGy

DLP

____________ mGy-cm

Reason for Exam/Clinical Symptoms:

I have reviewed this information with the patient or their legal guardian, power of attorney, next of kin, etc. and performed a clinical pause.

Technologist Signature:

Date:

Attachment A007 (a)

Revised January 1, 2014

Ct Patient Screening Form

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