Skip to content
Physician Login
Employee Login
Home
About
Services
MRI
Dexa Scan
Digital X-Ray
Ultrasound
Pain Management
CT Scan
Mammography
Locations
Patient Forms
CT & IV Contract Form
Mammogram Form
MRI Form
Ultrasound History and Screening Form
X-Ray History and Screening Form
Blog
Contact
Home
About
Services
MRI
Dexa Scan
Digital X-Ray
Ultrasound
Pain Management
CT Scan
Mammography
Locations
Patient Forms
CT & IV Contract Form
Mammogram Form
MRI Form
Ultrasound History and Screening Form
X-Ray History and Screening Form
Blog
Contact
Ultrasound History and Screening Form
Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information
This information will be sent to your provider and will be kept as part of your patient records.
First Name
Middle Name
Last Name
Address
Date
Sex
Male
Female
Height
Weight (lbs)
Date of Birth
Age
Referring Physician
Procedure
Email Address
Mobile phone number
Are you pregnant
Yes
No
N/A
Last Menstrual Period
Number of Pregnancies
Reason you are here today
Explain your medical problem in detail. (What happened? Where did it happen? How long have you had this problem?)
Do you have pain?
Yes
No
Where?
Have you had any surgeries in the area(s) that are being imaged today?
Yes
No
Where?
Have you had a previous exam related to this problem?
Yes
No
If yes, please explain
List all locations of your pain or symptoms on your body
Acknowledgement: 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 at this time I am pregnant OR NOT pregnant.
Initial
Patient Name
Patient Signature
Date
Diabetic: Y or N
HBP: Y or N
Allegergies: Y or N
Pregnant/Breastfeeding: Y or N
Kidney Problems: Y or N
Pacemaker/Metal /Implants/Pain Pumps/Neurostimulator/Stents:
Does PT have an implant card? Y or N
Visitor Screening Questionnaire
Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N
Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N
Within the past 14 days, I have been sick with a cold or flu: Y or N
Within the past 7 days, I have had a fever: Y or N
Within the last 7 days, I have had nausea and vomiting and/or loss of taste and /or smell: Y or N
Within the last 7 days, I have had diarrhea: Y or
I now have symptoms of a cold or flu: Y or N
I now have a fever: Y or N
Within the past 14 days, I have been around people who have been or are sick with colds or flu: Y or N
I have been nauseated or have vomited or had diarrhea within the past week: Y or N
I have received the COVID-19 Vaccination: Y or N - if yes, please indicate which arm.
Identification Card: Please upload your picture ID card.
Please review to ensure the details are correct before completion.
Submit
Home
About
Services
MRI
Dexa Scan
Digital X-Ray
Ultrasound
Pain Management
CT Scan
Mammography
Locations
Patient Forms
CT & IV Contract Form
Mammogram Form
MRI Form
Ultrasound History and Screening Form
X-Ray History and Screening Form
Blog
Contact
Physician Login
Employeee Login
Request an Appointment Today
Are you a new or returning patient?
New
Returning
Male
Female
Other
--Select Location--
Medical Center
Kirkwood
Red Oak
Katy
Sugar Land
Fallbrook
Bay Colony
Woodlands
Baytown
Order/Insurance Info
Upload ID
I have read and agreed to
Privacy Policy
and
Terms of Use
and I am at least 13 and have authority to make the appointment.
I agree to receive text messages from this practice and understand that message frequency and data rates may apply.
Request Appointment
