CT Scan Request Form 1 New
CT Scan Request Form 1 New
Date Requested: __________ / ________ / _________ Out-Patient: In Patient: Room No: ___________
BIRTHDATE: _________ / _____ / _________ AGE: _________ SEX: _________ CONTACT NUMBER: __________________________________
ADDRESS: ___________________________________________________________________________________________________________
CHIEF COMPLAINT:
____________________________________________________________________________________________________________________
CLINICAL IMPRESSION:
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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
*IF SAME PART IS TO BE SCANNED PLEASE BRING PREVIOUS CT PLATES AND REPORT FOR COMPARISON.