Patient Medical History Form

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Patient Label
Page 1 of 1
Patient Medical History Form
#IMG-208
Revised 11/10
QUESTIONNAIRE
PATIENT MEDICAL HISTORY FORM
Your Name: _____________________________________________ Your Physician: ________________________________________
Your phone # in case we need to contact you: _____________________________________________________________________
Current emergency contact and phone number: ____________________________________________________________________
Type of Procedure you are here for today: _________________________________________________________________________
What problems or complaints are you having that prompted your doctor to order this test?
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
How long have you had these symptoms? _____________________________________________________________________
Do you have, or have you had, cancer or a tumor?
Yes
No
If yes, when did you first know about it? Month/Year, ___________________________________________________________
Where was/is the cancer or tumor? ___________________________________________________________________________
Have you had:
Chemotherapy
Radiation Therapy
What part of the body was treated? ___________________________________________________________________________
Have you had any of these tests that relate to your current condition? (Check all that apply)
CT
MRI
Ultrasound
Nuclear Medicine Scan
Xray
If yes, where were they done? ________________________________________________________________________________
Did any of these tests done in the past 12 months show any abnormality?
Yes
No
If yes, please describe them briefly? ___________________________________________________________________________
Have you ever had any contrast material (dye) injected into your arteries or veins for an xray or CT test?
Yes
No
If yes, did you have a reaction to the contrast?
Yes
No
What kind of reaction did you have? ___________________________________________________________________________
List any previous operations you have had and what, if any, organs you have had removed.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Do you have, or have you had in the past, any of the following medical problems?
High Blood Pressure
Hepatitis / Stomach / Bowel
Heart Attack / Surgery
Urinary / Kidney / Prostate
Asthma / Bronchitis
Uterus / Ovary
Diabetes / Pancreatitis / Thyroid
Stroke / Neurological
Are any of these past problems related to your current symptoms, please explain:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

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