5007 Summerville Rd ● Phenix City, AL. 36867
Phone: 334-408-2854 ● Fax: 334-384-9274
www.2bridgeway.com
CT CLINICAL HISTORY SHEET
PATIENT NAME: _________________________________________
PATIENT DOB: _______________________PT HT: ___________
PT ID: _________________
PT WT: ________________
PLEASE LIST SYMTOMS YOU ARE HAVING WHICH RELATES TO TODAYS EXAM:
_________________________________________________________________________________
PLEASE COMPLETE ALL QUESTIONS:
Have you ever had surgery or biopsies relating to any of these areas? (If yes please briefly explain in the
comment area provided):
1.
2.
3.
4.
Head
Neck
Chest
Abdomen (stomach)
YES
YES
YES
YES
NO
NO
NO
NO
5.
6.
7.
Pelvis
Spine
Other
YES
YES
YES
NO
NO
NO
Type of Surgery/Biopsy:
_________________________________________________________________________________________
_________________________________________________________________________________
Have you ever been injected with x-ray dye?(IVP,CT Scan,Venogram,Arteriogram,Heart Cath) YES
NO
Have you ever had any of the following imaging tests:
WHEN
WHERE
CT
YES
NO
______________
_________________________
PET
YES
NO
______________
_________________________
MRI
YES
NO
______________
_________________________
ULTRASOUND
YES
NO
______________
_________________________
NUCLEAR MEDICINE
YES
NO
______________
_________________________
MAMMOGRAM
YES
NO
______________
_________________________
Have you ever had any radiation treatments? YES NO If so, what area of the body? _____________________
Have you received any chemotherapy?
YES NO If so, when?__________________________________
Is there a possibility that you may be pregnant?
YES
NO
Breast Feeding?
YES
NO
______________________________________________________
Patient Signature
______________________
Date