X-Ray 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.

Are you pregnant

Yes No N/A

Last Menstrual Period

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

Do you have any of the following?

Please explain for each "yes" above

List all locations of your pain or symptoms on your body

List all locations of any metal in 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/Parent/Legal Guardian Signature

Informed Consent For X-ray

You have the right to be informed about the diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you may choose to give or withhold your consent to the procedure. If you are pregnant or think that you may be pregnant, please inform the technologist at once. Your physician has requested that we perform x-rays to obtain additional information. This is a diagnostic test that involves x-ray images and a computer to produce an image of internal body parts.
Your physician believes an x-ray to be the best diagnostic test for you, considering your symptoms and condition. The benefit of this exam is to assist your physician with a diagnosis.

I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, I (WE) HAVE READ IT OR HAVE HAD IT READ TO ME (US), THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS.

THE PROCEDURES TO BE USED, AND THE RISKS AND HAZARDS INVOLVED, AND I (WE) BELIEVE THAT I (WE) HAVE SUFFICIENT INFORMATION TO GIVE THIS INFORMED CONSENT.

Patient Name Printed

Claustrophobic: Y or N

Allergic to Iodine: 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

Identification Card: Please upload your picture ID card.

Please review to ensure the details are correct before completion.

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