Scribd
Upload
61 views1 page

CT Scan Request Form 1 New

Uploaded by

tsihryiesamineybanez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
61 views1 page

CT Scan Request Form 1 New

Uploaded by

tsihryiesamineybanez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

CT-SCAN REQUEST FORM

Date Requested: __________ / ________ / _________ Out-Patient: In Patient: Room No: ___________

________________________________ _____________________________________ _____________________________________


LAST NAME FIRST NAME MIDDLE NAME

BIRTHDATE: _________ / _____ / _________ AGE: _________ SEX: _________ CONTACT NUMBER: __________________________________

ADDRESS: ___________________________________________________________________________________________________________

CT - SCAN PROCEDURE: ________________________________________________________________________________________________

REQUESTING PHYSICIAN: _______________________________________________________________________________________________

CHIEF COMPLAINT:

____________________________________________________________________________________________________________________

CLINICAL IMPRESSION:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

SHORT MEDICAL HISTORY and PERTINENT PHYSICAL EXAMINATION FINDINGS:

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

CONDITION YES NO IF YES, since when? When was the last time it happened?
ASTHMA
HYPERTENSION
DIABETES
INSULIN DEPENDENT? IF YES, PLS. SPECIFY
TAKING METFORMIN? IF YES, PLS. SPECIFY
CARCINOMA IF YES, PLS. SPECIFY
ALLERGIES

PREVIOUS SURGERY/OPERATION: YES NO

IF YES, SPECIFY (include Date)_________________________________________________________________

PREVIOUS CT-SCAN: YES NO

IF YES, IF YES, SPECIFY (include Date) __________________________________________________________________

*IF SAME PART IS TO BE SCANNED PLEASE BRING PREVIOUS CT PLATES AND REPORT FOR COMPARISON.

FOR CT PROCEDURE WITH CONTRAST:

CREATININE RESULT ________________________ DATE _______ / ______ / ________

*PLEASE FILL OUT THIS FORM COMPLETELY AND LEGIBLY.

You might also like