CT and IV Contrast History and Screening Form

Choose Location *

MaleFemale

YesNoN/A


YesNo


Not applicable to this exam

YesNo

YesNo

YesNo

PERSONAL HISTORY:

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo


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.



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