Name

Weight

Height

Date of Birth

Sex

Follow-up Appointment Date w/ Doctor

Claustrophobic

Pregnant

Allergies

Please describe your symptoms on the area being scanned

Are you in pain?

Where?

For how long have you had the pain?

Are your symptoms a result of an accident?

Date of Injury

Type of Injury

Please list all related surgeries and dates

Do you smoke or have you smoked in the past?

How long?

Have you been diagnosed with Cancer?

Where in the body?

Have you had chemotherapy?

When?

Have you had radiation therapy?

When?

Are you diabetic?

What medications do you take?

Do you have any medical conditions?

Please explain

Where and when have you had any previous studies related to today's visit?

Patient History (English)