Princeton Radiology Chest/Abdomen/Pelvis CT Questionnaire

  • MM slash DD slash YYYY
    Is there any chance you may be pregnant?
  • MM slash DD slash YYYY
    Do you wear a Dexcom, Libre, or other glucose monitor?
    Do you have unexplained fever?
    Are you immunocompromised? If uncertain, select NO.
    Do you have a history of being diagnosed with cancer?
    Any radiation therapy?
    Any chemotherapy?
    Are you in a lung cancer screening program with yearly CTs of the chest?
    Do you now or have you ever smoked?
    Any prior imaging of the area?
    Any prior surgery of the area?
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  • This field is for validation purposes and should be left unchanged.