Query Form What is this questionnaire for?* PET CT Diagnosis/reason for referral* Patient InformationFirst Name* Last Name* Age*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*- select -MaleFemaleEmail* Cell Phone*Home Phone*Height* Weight* Attending PhysicianPhysician Referral* Second Opinion Consultation with Specialist Physician Name* Physician Contact* Physician Address* Diagnosis* Date of diagnosis*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Special instructions from referring physician PET Specific QuestionsPET Services* Oncology Diagnosis/Tumor Brain Heart Did you had any Biopsies/Surgeries?* Yes No When did you had your Biopsy/Surgery*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Incision site* Do you have an "ostomy", catheter, portacath or drain?* Yes No Location of device* Do you have any other medical problems or injuries?* Yes No Other medical problems or injuries*Have you had chemotherapy?* Yes No Date of Chemotherapy*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you had Radiation Therapy?* Yes No Date of Radiation Therapy*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PET Female Specific SectionAre you pregnant?*- select -YesNoAre you nursing?*- select -YesNoLast menstrual period* Do you have breast implants?*- select -NoYes, Left breastYes, Right breastYes, Both breastsCT Specific QuestionsCT Services* Add 3-D / Multiplanar Reconstruction Oral Contrast IV Contrast Brain Orbits Temporal Bones Sinuses - Limited Sinuses - Complete Neck Chest Abdomen Pelvis Abdomen/Pelvis Extremity Spine - Cervical Spine - Thoracic Spine - Lumbar Do you have an occupational exposure history?* Yes No (eg. asbestos, chemicals, fumes, etc)Occupational exposure history* Do you have a smoking history?*- select -NoneCurrent smokerStopped smokingHow many cigarette packs/day?* When did you stop smoking?*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Any family history of cancer?*- select -YesNoAny personal history of cancer?*- select -YesNoFamily history of Cancer* Personal history of Cancer* Do you have symptoms in the chest area?* Yes No Explain symptoms in the chest area* Do you have symptoms in the abdominal area?* Yes No Explain symptoms in the abdominal area* Have you experienced recent unintentional weight loss?* Yes No Unintentional weight loss symptoms* General InformationAre you a diabetic?* Yes No Do you take Metformin?*- select -YesNoDo you take Insulin?*- select -YesNoMetformin - Date last taken*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insulin - Date last taken*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Blood glucose level* When did you last exercise?* Do you have any allergies to medications, latex, contrast dye?* Yes No I am allergic to the following*Medication*- select -I am aware of my current medicationI am aware of my current medication but not 100% sureI am not aware of my current medicationList of current medications*Please include all vitamins, herbals, patches, oral contraception, ointments and over the counter medicines.Additional patient commentsRecent Imaging* CT MRI Date of CT*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CT Imaging Facility* Date of MRI*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MRI Imaging Facility* Are you claustrophobic?* Yes No Have you ever been prescribed medication for it?* Insurance InformationAre you insured?* Yes No Insurance Company*Bahama HealthAtlanticGeneralliOther ...Insurance company name* Telephone number*Group number* Policy number* ID number* Claim number* Authorization number* If you are not insured we accept payment with cash or credit card.Privacy Policy ConsentConsent* I agree to the privacy policy.By accepting the terms of this Agreement, I give my consent to the processing of my personal data by Pet CT International. This information is stored in our database This is and will only be the property of PET CT International and never shared with any person, company or affiliate. CAPTCHA