Brandywine
Omega Imaging
Pike Creek
Glasgow

Patient Number:
Date: xx/xx/xxxx
First Name: Middle: Last:
Birthdate: xx/xx/xxxx      Age:    
Email Address:
   
Requesting Doctor:
Family Doctor:

Why do you need this test?


Possibility of being pregnant? yes no
If yes, Last Menstuation Period? xx/xx/xxxx


Clinical Information
Check if yes

Head
Seizures     Left     Right
Headaches     Left     Right
Dizziness     Left     Right
Fainting Spells     Left     Right
Speech Difficulty     Left     Right
Memory Loss     Left     Right
Paralysis     Left     Right
Weakness     Left     Right
Numbness     Left     Right
Hearing Loss     Left     Right
Loss of Vision     Left     Right

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)

Head Injury: yes no     Date: Place:
Previous brain or sinus Surgery: yes no     Date:
Stroke: yes no     Date:
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


Previous Examinations:
(give dates and places if known)

MRI of Head   Date: Where:
CT of Head  Date: Where:
Skull X-rays   Date: Where:
Cerebral arteriogram  Date: Where:
Nuclear Medicine Scan  Date: Where:
EEG  Date: Where:
Others, specify: Date: Where:




Technologist: ,RT