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    kyle
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    This document contains a radiology department form asking for patient medical history information such as any ongoing lung disease treatment, symptoms of coughing or fever, pregnancy status, last menstrual period date, history of surgery, and the reason for the exam or list of problems. The form requests a signature and is duplicated on the page.

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    This document contains a radiology department form asking for patient medical history information such as any ongoing lung disease treatment, symptoms of coughing or fever, pregnancy status, last menstrual period date, history of surgery, and the reason for the exam or list of problems. The form requests a signature and is duplicated on the page.

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    © All Rights Reserved
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    18 views2 pages

    Radiology Department

    Uploaded by

    kyle
    This document contains a radiology department form asking for patient medical history information such as any ongoing lung disease treatment, symptoms of coughing or fever, pregnancy status, last menstrual period date, history of surgery, and the reason for the exam or list of problems. The form requests a signature and is duplicated on the page.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    RADIOLOGY DEPARTMENT RADIOLOGY DEPARTMENT

    IS PATIENT ONGOING TREATMENT TO ANY LUNG DISEASE? IS PATIENT ONGOING TREATMENT TO ANY LUNG DISEASE?
     YES  YES
     NO  NO
    IF YES, SPECIFY IF YES, SPECIFY
    WHEN: WHEN:
     COUGH  COUGH
    WHEN: WHEN:
     FEVER  FEVER
    WHEN: WHEN:
    FOR FEMALE PATIENTS FOR FEMALE PATIENTS
    Is patient pregnant? Is patient pregnant?
     YES  YES
     NO  NO
    LMP: LMP:
    Signature: Signature:
    History of any Surgery? History of any Surgery?
     YES  YES
     NONE  NONE
    If Yes, specify If Yes, specify
    REASON FOR EXAM/PROBLEM LIST: REASON FOR EXAM/PROBLEM LIST:

    RADIOLOGY DEPARTMENT RADIOLOGY DEPARTMENT

    IS PATIENT ONGOING TREATMENT TO ANY LUNG DISEASE? IS PATIENT ONGOING TREATMENT TO ANY LUNG DISEASE?
     YES  YES
     NO  NO
    IF YES, SPECIFY IF YES, SPECIFY
    WHEN: WHEN:
     COUGH  COUGH
    WHEN: WHEN:
     FEVER  FEVER
    WHEN: WHEN:
    FOR FEMALE PATIENTS FOR FEMALE PATIENTS
    Is patient pregnant? Is patient pregnant?
     YES  YES
     NO  NO
    LMP: LMP:
    Signature: Signature:
    History of any Surgery? History of any Surgery?
     YES  YES
     NONE  NONE
    If Yes, specify If Yes, specify
    REASON FOR EXAM/PROBLEM LIST: REASON FOR EXAM/PROBLEM LIST:

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