Urology Northwest PS

We believe every
patient to be as unique
as the quilts adorning
our office walls.
We are committed to
finding the treatment
plan best suited for
each individual patient. 
Radiology CT Scan Pre Test Questionnaire

Radiology/CT Scan Patient Questionnaire
 
 
Have you ever had a CT scan or a kidney x-ray exam?____   Where?_______________
 
If yes, did you receive an injection of iodine?________________________________
 
If yes, did you have a reaction to this injection?_______ Type of Reaction?_________
 
Do you have Diabetes  Y      N;  If yes, what medication are you taking?
 
___________________________________________________________________
 
Are you aware of any kidney problems?__________ History of asthma?____________
 
 
Medication allergies:___________________________________________________
 
 
FEMALE PATIENTS of child bearing age:
 
Is there any chance that you are pregnant?______
 
When was your last menstrual cycle?__________
 
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Your signature indicates that you have answered the above questions to the best of your knowledge and you understand the possible risks of receiving an iodine injection and the possible side effects of ionizing radiation as they have been explained to you.
 
___________________________                            _________________________
Patient signature                                                             Patient name (printed)
 
Authorization for release of medical information
 
Your radiology exam will be interpreted by an independent radiology group.  In order for this group to make the best possible interpretation, they will need to know your past medical history, which you supplied to Urology Northwest, PS.  In addition insurance information will be supplied to the radiology group for billing purposes for the interpretation portion of the exam.  Your signature acknowledges the release of this medical and insurance information.  You may receive two bills for the exam.  One from Urology Northwest, PS for the technical component and one from the Radiology Group for the professional component of the exam.
 
________________________                                _________________________
Patient signature                                                            Patient name (printed)
 
________________________                                _________________________
Date                                                                                  UNW-Witness