Chest/Abdomen/Pelvis form - Princeton Radiology

First Name*

Last Name*

Email*

Date of Birth*

Sex

Male
Female

Weight in Pounds*

Why are you having the exam? (Symptom)

What side, location, body parts are involved? (Location)

How long have you had this problem? (Duration)

If due to injury, how did it occur? (Mechanism of Injury)

Is there any chance you may be pregnant?

Yes
No

Is there any chance you may be pregnant?

Date of last menstrual period?

Do you wear a Dexcom, Libre, or other glucose monitor?

Yes
No

Do you wear a Dexcom, Libre, or other glucose monitor?

Do you have unexplained fever?

Yes
No

Do you have unexplained fever?

Are you immunocompromised? If uncertain, select NO.

Yes
No

Are you immunocompromised? If uncertain, select NO.

Do you have a history of being diagnosed with cancer?

Yes
No

Do you have a history of being diagnosed with cancer?

If yes, What type of cancer?

Any radiation therapy?

Yes
No

Any radiation therapy?

If YES, what dates?

Any chemotherapy?

Yes
No

Any chemotherapy?

If yes, what dates and type?

Are you in a lung cancer screening program with yearly CTs of the chest?

Yes
No

Are you in a lung cancer screening program with yearly CTs of the chest?

Do you now or have you ever smoked?

Yes
No

Do you now or have you ever smoked?

If YES, how many years did you smoke?

How many packs per day did you smoke?

How long ago did you quit? If still smoking, mark as “0”

Any prior imaging of the area?

Yes
No

Any prior imaging of the area?

Where/when?

Any prior surgery of the area?

Yes
No

Any prior surgery of the area?

Type/dates?

I acknowledge that all the information given is accurate and thereby consent to have CT with or without an injection of contrast performed on me.*

Yes, I Agree
No, I Do Not Agree

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Technologist Initials

Comments

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Princeton Radiology Chest/Abdomen/Pelvis CT Questionnaire

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