Microsoft word - ct screening form.doc

First Name:__________________________ M.I. _____ Last Name:____________________________ Male / Female D.O.B:_________________ Employer: _____________________________ MARRIED / SINGLE / OTHER Home Phone: _______________________ Cell: _____________________ Work: ________________________
Address: ____________________________City/State/Zip Code: _____________________________________________
Primary Cardholder’s Name on Insurance: ________________________________ Relation: Self / Spouse / Child
Subscribers D.O.B: __________ Subscribers Employer:___________________________ SS#:_____________________
Please answer the following questions. For your safety, please circle Yes or No and answer completely:
Have you had a prior CT scan that pertains to today’s exam and where? ________________________________________
What medications do you currently take?________________________________________________________________
What is your weight? ____________________________
List any surgeries?__________________________________________________________________________
Yes No Are you Allergic to Iodine? List all Drug/Food Allergies you have:
Yes No Have you had any IV contrast within the past 48 hours? ________________________________
Yes No Do you have both kidneys? ______________________________
Yes No History of Kidney Surgery? ______________________________
Yes No Asthma or Lung problems? ______________________________
Yes No Hepatitis or Jaundice? __________________________________
Yes No Epilepsy/Seizures? _____________________________________
Yes No High Blood Pressure (hypertension)? _______________________________________________
Yes No Heart Problems? _______________________________________________________________
Yes No History of Cancer; If yes, explain:___________________________________________________
Yes No Stomach/Intestinal Problems; If yes, explain: __________________________________________
Yes No Multiple Myeloma; If yes, explain: __________________________________________________
Yes No Stroke; If yes, explain: ___________________________________________________________
Yes No Bladder Problems; If yes, explain: __________________________________________________
Yes No Metal Implants/Foreign Objects; If yes, explain: _______________________________________
Yes No DIABETIC OR RENAL DISEASE? _____________________________________________________
WHAT ARE YOUR SYMPTOMS? ______________________________________________________________
If Diabetic, do you take Metformin Medications (Glucophage, Glucovance, Avadament, Metaglip, Fortamet, or Riomet)?
PLEASE NOTIFY YOUR PHYSICIAN FOR ADVISEMENT*******************************************
FOR FEMALE PATIENTS OF CHILD BEARING AGE; COMPLETE THE FOLLOWING: Please check all that apply; if none please complete below information: I have had a Hysterectomy I have had a tubal ligation Are you Pregnant? Yes / No Are you Nursing? Yes / No Birth Control Information (If Applicable): My birth control method is ___________________________. The dates of my last menstrual cycle are/were ___________________ to _______________________. Consent: I have answered all the questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that I am NOT pregnant at this time. Patient Signature: _______________________________________________ Date: ____________________________ ________________________________________________________________________________________________ FOR TECH USE ONLY: CREATININE _____________ IV SITE: ___________ GAUGE: ___________ TECH: ____________


On behalf of the german society of neurology (dgn) we developed guidelines on neurogenic dysphagia (nd), which were accepted i

Guidelines of the German Society of Neurology (DGN) on Neurogenic Dysphagia (ND) Mario Prosiegel Neurologisches Krankenhaus München (NKM), Tristanstr. 20, D-80804 Munich, Germany The abovementioned guidelines were accepted by the DGN guidelines commission in September 2004 and will be published by the DGN in 2005. The main recommendations of these guidelines are as follows: ! Diagnosis o

Microsoft word - camp edow 2013 health form.doc

Due July 1, 2013 via mail – All information required •   ri •   is al Camper Name__________________________________________ Birthdate ( Month, Day, Year )__________________ Parent/Guardian with legal custody to be contacted in case of illness or injury: Name___________________________________ Relationship to camper______________________________________ Preferred Phone: ( )

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