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Patient Health History Questionnaire – CT Iodinated Contrast Creatinine & Date of Labs:__________________________________________________ Examination:______________________________________________________________ Your physician has requested that you have an examination, which requires the injection of iodinated contrast material into your bloodstream. Immediately after the injection, many patients notice nausea, a warm and flushed feeling as well as a metallic taste in their mouth. Contrast material is considered quite safe; however, any injection carries slight risk of harm including injury to a vein, infection or reaction to the material being injected. Occasionally, a patient will have a mild reaction to the contrast material and may experience sneezing and develop hives. Rarely (one to two in 10,000), a serious reaction to the contrast occurs. The physicians and staff of this facility are trained to treat these reactions.
Please indicate if you have any of the following: NO History of prior contrast material reaction If yes, please list:__________________________________________________ If yes, do you take Glucophage, Glucophage xR, Fortamet, Glumetza, Riomet, Gluvovance, Metaglip, Have you ever had a previous examination with radiographic contrast material injected into your veins? If yes, were there any problems:_____________________________________________________ Please direct any questions concerning this examination to the Imaging Staff who will be happy to discuss your questions with you.
I have read this form and understand this form and give my consent for intravenous Print Patient Name:__________________________________________________________ Signature of Patient:_________________________________________________________ Signature of Witness:________________________________________________________ This information will help the Physician with the interpretation of your diagnostic test.
Last Name:_____________________________ First:_________________________ Age:_____ Date of Birth:___________ Dominant Hand:__________ Height:______ Weight:______ Occupation:_______________________________ Describe the health problem or symptoms that you are being tested for today:__________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ How long have you had this problem or symptoms? ____________________________________________________________ Is this problem the result of an injury? YES NO Date of injury:_________________________________________ Have you had surgery or radiation therapy in the area of your body being scanned today? If yes, please describe what treatment was performed? _________________________________________________________ __________________________________________________________________________________________________________ Have you had any prior imaging of the area being tested today? When/Where? X-ray:____________________________________________________________________________________________________ MRI:_____________________________________________________________________________________________________ Ultrasound:_______________________________________________________________________________________________ CT:_______________________________________________________________________________________________________ Bone scan/PET CT/Angiogram:______________________________________________________________________________ Mammography:___________________________________________________________________________________________ DEXA/QCT Bone Density:___________________________________________________________________________________ Please provide any other information about your health that you feel may be important for us to know before we perform your test. (Examples: Cancer, Asthma, Diabetes) Patient Demographic / Insurance Information Last Name:__________________________ First:___________________________________ MI:____ Date of Birth:________________ Address:_____________________________ City:___________________________________ State:_______ Zip Code:_____________ Home Phone:____________________________________________ Cell Phone:________________________________________________ Emergency Contact Name:_____________________________________________________ Phone:______________________________ Employer:_______________________________________________ Work Related? YES Referring Physician:______________________________________ Primary Physician:_________________________________________ Primary Insurance Company Name:______________________________________________________ ID #:_______________________ Address:_____________________________ City:___________________________________ State:_______ Zip Code:_____________ Name of Insured:______________________________________________________________ Date of Birth:________________________ Patient Social Security #:_________________________ Secondary Insurance Company Name:___________________________________________________ ID #:_______________________ Address:_____________________________ City:___________________________________ State:_______ Zip Code:_____________ Name of Insured:______________________________________________________________ Date of Birth:________________________ ASSIGNMENT BENEFITS I hereby authorize and direct my insurance carrier to pay directly to this provider of medical services any benefits due under my insurance plan, I also hereby authorize this provider to use and disclose any of my personal medical information for treatment/diagnosis and payment (including to my insurance company), I agree to pay the balance of charges not paid under my plan. Should the account be referred to an attorney for collection, the undersigned shall pay attorney’s fees and other collection expenses.
IF I AM UNINSURED, I am fully responsible for all charges. Date:________________________ Signature:________________________________________________________________________ PATIENT PRIVACY In Accordance with city, state, and federal laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Regents Imaging will protect patient records and other information that may reveal a patient’s identity when using or disclosing such information for purposes of treatment, payment, or health care operations. I am aware that I can request to review the policy posted at the front desk for patients. Date:________________________ Signature:________________________________________________________________________

Source: http://www.regentsimaging.com/wp-content/uploads/2012/09/NCR_PatientForms_CT.pdf