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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
CT Patient Evaluation
Home
/
CT Patient Evaluation
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Name / Nombre
*
First
Middle
Last
How did you hear about us? / Como escucho sobre nosotros?
*
Age / Edad (copy)
*
Presently Pregnant? / Esta usted embarazada?
*
Yes
No
Diabetes
*
Yes
No
Multiple Myeloma / Mieloma múltiple
*
Yes
No
Hypertension (high blood pressure)? / presion arterial alta?
*
Yes
No
Renal Failure (kidney disease) / insuficiencia renal ( enfermedad del riñon)
*
Yes
No
Do you have Allergies? / Tienes alergias?
*
Yes
No
Please List / Por favor enumere
*
Do you take Medication / ¿Toma medicinas?
*
Yes
No
Please list / Por favor enumere
*
Have you had surgeries before?/ ¿Has tenido cirugías antes?
*
Yes
No
Please list / Por favor enumere
*
Previous Biopsy / Biopsia previa
*
Yes
No
Facility / Institución
*
Any history of cancer - type and where / Algun historial de cáncer - dónde y tipo
*
Previous Chemotherapy / quimioterapia previa
*
Yes
No
Radiation / Radiación
*
Yes
No
If you have had a prior study of the area we are scanning today, please list each below: / Si ya realizó un estudio previo del área que escaneamos hoy, marque cuales:
CT
MRI
XRay
Facility of CT scan / Instalación de CT
*
Facility of MRI scan / Instalación de MRI
*
Facility of XRay scan / Instalacion de Xray
*
Phone
Submit
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