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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)? If YES, please DO NOT TAKE YOUR METFORMIN MEDICATIONS FOR 48 HOURS AFTER RECEIVING IODINE CONTRAST INJECTION. 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: ____________
Miss Elizabeth Goad, Mr. Justin Tummins, Mr. Daniel Lewis, Mr. Tyler Lewis, Miss Amanda Hayes, and Mr. Chase Vaughan have all recently accomplished a great achievement by receiving their First Degree Black Belt and Certificate presented by Tony Lewis, owner and chief instructor of Dickson Taekwondo (608 Henslee Drive). 615-446-5622 www.dicksontaekwondo.com Miss Elizabeth Goad said that Taek
Blessed with the love of God Fr. Joe O’Mara SJ reminds us that sickness is no less a gift than health In 1998 I had cancer, which was removed, and chemotherapy. I had physiotherapyand acupuncture in rehabilitation. In 2003 I had bypass surgery, and kept gettingrecurrent pneumonia through 2004 (when I was blessed by joining this commu-St Ignatius Parish Renewal and Sharing Committee