Phone: 713.425.8100 • Fax Orders: 713.425.8182
q 2600 N. Gessner, Ste. 150, Houston, TX 77080
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Patient name: ___________________________________________________________________________________________________ Date: _______/_______/___________ Type of exam: CT ___________________________________________________________ Weight: ________ Height: ________ (Female patients): Are you pregnant, or suspect you may be pregnant? q Yes q No When is your next follow up appointment with your doctor? ________________________________________________________ Explain present condition (How and When you were injured? Where is your pain, and for how long?): _______________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Do you have or have you had any of the following: Rheumatoid Arthritis/Scleroderma q Yes q No Please list any other medical conditions not listed above: ________________________________________________________________________________________________________________ List any and all past surgeries and the year they were done: _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Have you had any previous imaging studies related to today’s procedure? If yes, please list type of study, date and location: ________________________________________________________________________________________________________________ If yes, do you take any medications containing metformin such as Glucophage, Glucovance, Avandamet, Janumet, or Metaglip? If you are taking any of the medications listed above, it must be withheld for 48 hours following the exam. Did your Doctor instruct you to do this? If yes, please list:_____________________________________________________ Have you had intra-venous iodine injected into a vein? q Yes q No If yes, please check if you had: Describe: _________________________________________________________________________________________________________ TECHNOLOGIST SECTION
Contrast type: ________________________ Amount injected: __________________________ Amount wasted: _________________________
Exp Date: _____________________________ Lot: ______________________________________ # of IV attempts: _________________________
q Yes q No Injection site: _____________________________ Injection time: __________________________ q Yes q No Post-proc instructions given? q Yes q No Completed by: ________________________ Date: _____________________________________ Time: __________________________________ Copyright 2011 Houston MRI & Diagnostic Imaging.

Source: http://www.houstonmri.com/pdf/ct-patient-history.pdf

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