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? *

Diabetes *

Multiple Myeloma / Mieloma múltiple *

Hypertension (high blood pressure)? / presion arterial alta? *

Renal Failure (kidney disease) / insuficiencia renal ( enfermedad del riñon) *

Do you have Allergies? / Tienes alergias? *

Please List / Por favor enumere *

Do you take Medication / ¿Toma medicinas? *

Please list / Por favor enumere *

Have you had surgeries before?/ ¿Has tenido cirugías antes? *

Please list / Por favor enumere *

Previous Biopsy / Biopsia previa *

Facility / Institución *

Any history of cancer - type and where / Algun historial de cáncer - dónde y tipo *

Previous Chemotherapy / quimioterapia previa *

Radiation / Radiación *

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 *

Name

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

(813) 964-8439
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