Summarized Print Form

What is this questionnaire for?*

PET
CT

Diagnosis/reason for referral*

Patient Information

First Name*

Last Name*

Age*

Date of Birth*

Gender*

Email*

Cell Phone*

Home Phone*

Height*

Weight*

Attending Physician

Physician Referral*

Second Opinion
Consultation with Specialist

Physician Name*

Physician Contact*

Physician Address*

Diagnosis*

Date of diagnosis*

Special instructions from referring physician

PET Specific Questions

PET Services*

Oncology Diagnosis/Tumor
Brain
Heart

Did you have a recent biopsy /surgery?*

Incision site*

Do you have an "ostomy", catheter, portacath or drain?*

Yes
No

Location of device*

PET Female Specific Section

Are you pregnant?*

Are you nursing?*

Last menstrual period*

Do you have breast implants?*

CT Specific Questions

Do you have an occupational exposure history?*

Yes
No

(eg. asbestos, chemicals, fumes, etc)

Occupational exposure history*

Do you have a smoking history?*

How many cigarette packs/day?*

When did you stop smoking?*

Family 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*

Amount of weight loss (lbs or kg)*

General Information

Are you a diabetic?*

Yes
No

Do you take Metformin?*

Do you take Insulin?*

Metformin - Date last taken*

Insulin - Date last taken*

When did you last drink liquids?*

Blood glucose level*

When did you last exercise?*

Do you have any allergies to medications, latex, contrast dye?*

Yes
No

Do you have food allergies?*

Medication*

List of current medications*

Please include all vitamins, herbals, patches, oral contraception, ointments and over the counter medicines.

Additional patient comments

Recent Imaging*

CT
MRI

Date of CT*

CT Imaging Facility*

Date of MRI*

MRI Imaging Facility*

Are you claustrophobic?*

Yes
No

Have you ever been prescribed medication for it?*

Insurance Information

Are you insured?*

Yes
No

Insurance Company*

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 Consent

Consent*

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.

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