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Ultrasound History and Screening Form

Fill out the form online or bring a printed copy to your appointment—whichever is easiest for you.

1Patient Information

2Visitor Screening Questionnaire

Patient Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

Date(Required)

MM slash DD slash YYYY

Sex(Required)

Male

Female

Height(Required)

Weight (lbs)(Required)

Date of Birth(Required)

Age(Required)

Referring Physician(Required)

Procedure(Required)

Email Address(Required)

Mobile phone number(Required)

Are you pregnant(Required)

Yes

Last Menstrual Period(Required)

Number of Pregnancies(Required)

Reason you are here today(Required)

Explain your medical problem in detail. (What happened? Where did it happen? How long have you had this problem?)(Required)

Do you have pain(Required)

Yes

Where?(Required)

Have you had any surgeries in the area(s) that are being imaged today?(Required)

Yes

Where?(Required)

Have you had a previous exam related to this problem?(Required)

Yes

If yes, please explain(Required)

List all locations of your pain or symptoms on your body(Required)

Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that at this time I am pregnant OR NOT pregnant.(Required)

Initial

Patient Name(Required)

Patient Signature(Required)

Date(Required)

Diabetic: Y or N(Required)

HBP: Y or N(Required)

Allegergies: Y or N(Required)

Pregnant/Breastfeeding: Y or N(Required)

Kidney Problems: Y or N(Required)

Pacemaker/Metal /Implants/Pain Pumps/Neurostimulator/Stents:(Required)

Does PT have an implant card? Y or N(Required)

Visitor Screening Questionnaire

Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N(Required)

Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N(Required)

Within the past 14 days, I have been sick with a cold or flu: Y or N(Required)

Within the past 7 days, I have had a fever: Y or N(Required)

Within the last 7 days, I have had nausea and vomiting and/or loss of taste and /or smell: Y or N(Required)

Within the last 7 days, I have had diarrhea: Y or N(Required)

I now have symptoms of a cold or flu: Y or N(Required)

I now have a fever: Y or N(Required)

Within the past 14 days, I have been around people who have been or are sick with colds or flu: Y or N(Required)

I have been nauseated or have vomited or had diarrhea within the past week: Y or N(Required)

I have received the COVID-19 Vaccination: Y or N- If yes, please indicate which arm.(Required)

Identification Card: Please upload your picture ID card.(Required)

Max. file size: 128 MB.

Complete the form below, and our team will respond promptly to assist you with your appointment or inquiry.

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MRI Digital X-Ray Ultrasound CT Scan Mammography

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16281 Imperial Valley Dr Suite K,
Houston, TX 77060

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