CT Scan Questionnaire (Questionario de - Southwest X-Ray

CT Scan Questionnaire (Questionario de - Southwest X-Ray

CT Scan Questionnaire (Questionario de Tomografia Computarizada)
Patient name (Nombre del paciente):
Today’s date (Fecha):
Date of Birth (Fecha de nacimeinto):
Physician (Doctor):
Type of CTY scan ordered today (Tipo de examen):
Reason for this exam/ symptoms (Razón para este examen):
Have you had a CT scan before? (Ha tenido una tomografia antes?)
Where (¿Dónde?)
When (¿Cu ndo?)
Type of exam (Tipo de examen):
Any history of surgeries(¿Ha tenido cirugía?)
When (¿Cu ndo?)
Type (Tipo):
Yes (Sí)
Yes (Sí)
No (No)
No (No)
Are you pregnant or suspect you might? (¿Est embarazada ó sospecha estarlo?) Yes (Sí)
Date of your last menstrual period. (Fecha del último periodo menstrual):
Are you diabetic (¿Es Diab tico(a)?)
Yes (Sí)
No (No)
Are you taking Glucophage or Metformin? (¿Est tomando Glucophage?) Yes (Sí)
No (No)
No (No)
List any medications you are currently taking. (Haga una lista de todos los medicamentos que est
tomando al momento):
Are you allergic to any medication? (Liste alergias (incluso a medicamentos):
Have you drunk the Barium? (A tomado el Barium?) Yes (Sí)
(Que es el tiempo completamente tomado el barium?)
No (No) What time did you finish?
Patient Signature (Firma del paciente):
1201 E. Schuster, 4B . El Paso, TX 79902 . Tel: 915-544-7300 . Fax: 915-544-7301
1720 Murchison . El Paso, TX 79902 . Tel: 915-544-7300 . Fax: 915-544-7301 . Email: [email protected]