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Home
About Us
Your Visit
For Physicians
- MD Login
- Scripts
Resources
For Lawyers
Blog
Contact
Patient Forms
FAQs

Chest X-Ray Questionnaire

Home / Chest X-Ray Questionnaire

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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

Name

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Contact

Call:(813) 964-8439
Email: info@bayviewradiology.com

Address

Bayview Radiology
Cypress Point Office Park
10010 N Dale Mabry Hwy
Suite 150
Tampa, FL 33618

Hours

Mon – Fri: 8am – 5pm
Tue & Thur: Extended CT & MRI until 8pm
Saturday by appointment

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