CT Screening CT and IV Contrast History and Screening Form Choose Location * ---AugustaAustin CentralBirminghamBuckheadCantonCareersCummingDallasDamond FarrarDecaturDiane GoodmanFayettevilleGrandviewHiramLawrencevilleMariettaNewnanSan AntonioSandy SpringsStand-up Mri AtlantaTallahasseVestaviaWest Cobb Patient Name: Date: Sex: MaleFemale Height: Weight: Age: Are You Pregnant? YesNoN/A Last Menstrual Period: Reason you are here for an exam today? Explain your medical problem in detail (What is the problem? Where is the problem? How long have you had this problem?): Have you had a previous exam related to this problem?: YesNo If yes, what type of exam? Where was exam? When was exam?: List other medical problem: List previous Surgeries: Medications presently taking: List any Drug or Food Allergies: Contrast History: Not applicable to this exam Are you taking Glucaphage?: YesNo BUN: CREATININE: HAVE YOU EVER HAD A PREVIOUS ALLERGIC REACTION OF X-RAY CONTRAST (DYE)?: YesNo If yes, explain: Have you been pre-medicated for this exam?: YesNo PERSONAL HISTORY: YesNoAsthma YesNoAllergic Respiratory Disease YesNoDiabetes YesNoKidney Disease YesNoCancer YesNoMultiple Myeloma YesNoProstate Problems YesNoAre you Breast Feeding at this time? YesNoDizziness YesNoHeart Disease YesNoStroke YesNoLiver Disease YesNoSeizure Disorder YesNoBladder Disease YesNoHeadaches If yes, explain: I have answered these 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/Parent/Legal Guardian Signature Technologist’s Signature Date: FOR TECHNOLOGIST USE ONLY Type of Contrast: Contrast Temperature: Lot Number: Expiration Date: Time of Injection: Amount: If you need to print a copy for office records, please select the Print button before submitting.