Allergies: yes no     Type:
Heart Problems: yes no
Kidney Problems: yes no
Asthma: yes no
Allergy to x-ray dye: yes no
Taking glucophage: yes no
Diabetic: yes no


Past History:
(give details if known)

Hospitalization or treatment of current problem?
Date: Place:
Previous Surgery: yes no     What Area:
Any known Tumor: yes no     What part of the body
Any other Surgery: yes no     What part of the body
Did you have Radiation? yes no
Or Chemotherapy? yes no

Additional Pertinent Information:



Previous Examinations:
(give dates and places if known)

X-ray of   Date: Where:
CT of   Date: Where:
Upper GI   Date: Where:
Barium Enema   Date: Where:
MRI   Date: Where:
Nuclear Medicine Scan   Date: Where:
Ultrasound   Date: Where:
Others, specify: Date: Where:




Technologist: ,RT