(813)964-8439
info@bayviewradiology.com
Home
About Us
Your Visit
For Physicians
MD Login
Scripts
Videos
Resources
Insurance Accepted
Payments
Consensus Radiology
For Lawyers
Contact
Patient Forms
Patient Information
MRI Screening
CT Patient Evaluation
Breast Imaging
Osteo Risk Sheet
Chest X-Ray Questionnaire
FAQs
Home
About Us
Your Visit
For Physicians
MD Login
Scripts
Videos
Resources
Insurance Accepted
Payments
Consensus Radiology
For Lawyers
Contact
Patient Forms
Patient Information
MRI Screening
CT Patient Evaluation
Breast Imaging
Osteo Risk Sheet
Chest X-Ray Questionnaire
FAQs
Chest X-Ray Questionnaire
Home
/
Chest X-Ray Questionnaire
[et_pb_section][et_pb_row][et_pb_column type=”4_4″][et_pb_text]
Please enable JavaScript in your browser to complete this form.
Name
*
First
Middle
Last
Injury to chest area / Lesión en el área del pecho
*
Yes
No
Please explain / Por favor explique
Chest pain / Dolor de pecho
*
Yes
No
Please explain / Por favor explique
Croup / Crup
*
Yes
No
Please explain / Por favor explique (copy)
Cough / Tos
*
Yes
No
Please explain / Por favor explique
Difficulty breathing / Respiración dificultosa
*
Yes
No
Please explain / Por favor explique
Pneumonia / Neumonía
*
Yes
No
Please explain / Por favor explique
Pulmonary disease / Enfermedad pulmonar
*
Yes
No
Please explain
Blood in sputum / Sangre en esputo
*
Yes
No
Please explain / Por favor explique
Hypertension / Hipertensión
*
Yes
No
Please explain / Por favor explique
Palpitations / Palpitaciones
*
Yes
No
Please explain / Por favor explique
Fracture in chest area / Fractura en el área del pecho
*
Yes
No
Please explain / Por favor explique
Cancer / Cáncer
*
Yes
No
Please explain / Por favor explique
Have you had a abnormal upper body radiological exam recently / Ha tenido un examen radiológico de la parte superior del cuerpo anormal recientemente
*
Yes
No
Please explain / Por favor explique
Abnormal blood gas / Gas sanguíneo anormal
*
Yes
No
Please explain / Por favor explique
Is this x-ray clearance for surgery / Es este aclaramiento de rayos x para cirugía
*
Yes
No
Please explain / Por favor explique
Do you have cardiac disease? / ¿Tienes una enfermedad cardíaca?
*
Yes
No
Please explain / Por favor explique
Have you received an abnormal arterial blood gas recently / ¿Ha recibido recientemente un gas sanguíneo arterial anormal?
Yes
No
Please explain / Por favor explique
Are you pregnant? / ¿Estas embarazada?
*
Yes
No
Message
Submit
[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section]
Contact Us
We're not around right now. But you can send us an email and we'll get back to you, asap.
Not readable? Change text.
I consent to Bayview Radiology collecting my details through this form.
Send