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X-Ray History and Screening Form

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

1Patient Information

2Informed Consent For X-ray

3Visitor Screening Questionnaire

Patient Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

Sex(Required)

Male

Female

Height(Required)

Weight (lbs)(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Email Address(Required)

Mobile phone number(Required)

Referring Physician(Required)

Are you pregnant(Required)

Yes

Last Menstrual Period(Required)

Reason you are here toda(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, explain(Required)

Do you have any of the following?

Asthma

Allergic Respiratory Disease

Diabetes

Kidney Disease

Cancer

Multiple Myeloma

Prostate Problems

Dizziness

Heart Disease

Stroke

Liver Disease

Seizure Disorder

Bladder Disease

Headaches

Orthopedic Pins/Rods/Screws/Plates/etc.

Please explain for each "yes" above(Required)

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

List all locations of any metal in 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.

Initial

Patient/Parent/Legal Guardian Signature(Required)

Date(Required)

Informed Consent For X-ray

You have the right to be informed about the diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you may choose to give or withhold your consent to the procedure. If you are pregnant or think that you may be pregnant, please inform the technologist at once. Your physician has requested that we perform x-rays to obtain additional information. This is a diagnostic test that involves x-ray images and a computer to produce an image of internal body parts. Your physician believes an x-ray to be the best diagnostic test for you, considering your symptoms and condition. The benefit of this exam is to assist your physician with a diagnosis.

(Required)

I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, I (WE) HAVE READ IT OR HAVE HAD IT READ TO ME (US), THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS.

(Required)

THE PROCEDURES TO BE USED, AND THE RISKS AND HAZARDS INVOLVED, AND I (WE) BELIEVE THAT I (WE) HAVE SUFFICIENT INFORMATION TO GIVE THIS INFORMED CONSENT.

Patient Name Printed(Required)

Patient Signature(Required)

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

Claustrophobic: Y or N(Required)

Diabetic: Y or N(Required)

HBP: Y or N(Required)

Allergic to Iodine: Y or N(Required)

Allegergies: Y or N(Required)

Surgery(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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Houston, TX 77060

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