Ultrasound History And Screening Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

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

Have you had any surgeries in the area(s) that are being imaged today?

Yes No

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

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.

Ultrasound History and Screening Form

Patient Information

Visitor Screening Questionnaire

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