Medical history form baptist m s imaging

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MEDICAL HISTORY FORM

Name: ______________________________________ Date of Birth: _____________ Last 4 numbers of SS#:_______

Referring Physician: _________________________________ Height: ________ Weight:________

Reason for Exam: _____________________________________________________________________________________

How long have you had this problem? _______________ Are you seeing your physician in the next 24 hours? Yes No

Medical history (check all that apply) Diabetes High blood pressure Smoking Kidney disease/failure Asthma

COPD Dialysis Multiple myeloma Adrenal Gland Tumor Heart Disease Lung Disease

Have you been treated for cancer?: Never Currently Previously

Treatment completed

Cancer type: ________________________________ Approximate date of cancer diagnosis: _________________________

List any major surgeries: ________________________________________________________________________________

Prior studies Have you had previous related imaging studies done? Yes No What part(s) of your body?_______________________

Where did you get these exams done? _____________________________________ What year? _____________________

Type of exam: X-Ray CT MRI Ultrasound Nuclear Medicine PETCT

Pregnancy Disclosure (section required for all female patients between the ages of 10 and 55) Initial:

______ No, I am not pregnant at the time of this x-ray examination / ______ Yes, I am pregnant at this time

______ I realize that x-rays/radiation may be harmful to my unborn child; however, I wish to continue with today's exam.

Have you had tubal ligation or partial/full hysterectomy? Yes No Date of last menstrual period (LMP): _____________

Iodine contrast history (only for patients having contrast exams)

Have you ever had previous imaging that required injection of contrast media/dye?

Yes No

Have you ever had an allergic reaction to IV Contrast used in any imaging procedure (CT, MRI, X-Ray)? ......... Yes No

Are you taking Glucophage? Glucovance? (Metformin) ........................................................................................ Yes No

Are you taking Avandament, Actoplusmet, Fortemet, Kombiglyze, Prandimet, Riomet, Glumetza, or Janumet? Yes No

Patient Signature:____________________________________________________________ Date: _________________

Baptist M&S Staff Full Signature:________________________________________________ Date: _________________ ----------------------- SECTION BELOW ONLY FOR TECHNOLOGIST AND BAPTIST M&S PERSONNEL -----------------------

Patient Fasting? Yes No Enteric Contrast: Rectal / Oral Type: ________________ Contrast Type Injected: _____ Volume ______ ml. Lot#:____________ Exp. Date: ___________ IV Access: Time: _________ Location: __________ Catheter Size/Type: __________ Number of Attempts: ____ IV Started By: ________________ Injected By:______________ Allergy problems post contrast? Yes No Date Lab Drawn: _________ Creatinine within normal limits: Yes No NA If no, Creatinine Level: _________ B.U.N. Level: __________ Notes:_________________________________________ ___________________________________________________________________________________________________

Baptist M&S Staff Full Signature:________________________________________________ Date: _________________

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