Ct Scan Patient Medical History Form

Download a blank fillable Ct Scan Patient Medical History Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Ct Scan Patient Medical History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

CT Scan Patient Medical History Form
Patient Name______________________________________
Date________________
Female□ Male□
MR#__________ Age______ DOB___________
Sex:
1. What is the reason for your exam today? _____________________________________
Yes□
No□
2. Have you ever had surgery?
If yes, please explain: ____________________________________________________
Yes□
No□
3. Have you ever been diagnosed with cancer?
Yes□
No□
4. Do you have kidney problems (circle all that apply)?
(Dialysis, single kidney, kidney transplant, kidney tumor, blood in urine)
If yes, please explain: ____________________________________________________
Yes□
No□
5. Are you diabetic?
Yes□
No□
6. Do you have High Blood Pressure?
Yes□
No□
7. Are you allergic to anything?
If yes, please explain: ____________________________________________________
Yes□
No□
8. Have you ever had a contrast injection?
Yes□
No□
Were there any complications?
If yes, please explain: ____________________________________________________
Yes□
No□
9. Is there any chance you could be pregnant?
Yes□
No□
Are you breastfeeding?
Yes□
No□
10. Do you have liver disease? (Transplant, cirrhosis or scarring)
Patient Signature___________________________________ Date__________________
Technologist Signature ______________________________ Date __________________

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 Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go