Touchstone Imaging XRAY Screening Form

First Name: _____________________________________ Last Name: ______________________________________

(Nombre)

Social Security Number: ____________________________________

DOB: _____________________ What is your weight? ______________ Male / Female

(Fecha de nacimiento) (Quanto pesas?)

What problems are you having related to today’s exam? (Relacionado al examen que se hara hoy, que problemas tiene?)

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List Prior Surgeries or Conditions: (Lista de Cirugías anteriores o en el Régimen):_____________________________

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Have you had prior imaging studies that relate to today’s current problem? NO / YES (list below)

(¿Ha tenido estudios previos de imágenes que se relacionan con el problema actual de hoy?)

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FOR FEMALE PATIENTS OF CHILD BEARING AGE / SOLO PARA MUJERES

PLEASE CHECK ALL THAT APPLY / MARQUE TODO LO QUE SE LE APLIQUE:

YES NO Is there any chance you are pregnant? (¿Hay alguna posibilidad de que está embarazada)

YES NO I am Pregnant / Estoy Embarazada YES NO I am nursing / Estoy dando pecho

YES NO I have had a Hysterectomy / Histerectomia YES NO I have achieved menopause / Menopausia

YES NO I am abstinent / Soy Abstinente YES NO Tubal Ligation / Ligacion de tubos

BIRTH CONTROL INFORMATION (IF APPLICABLE) /( INFORMACION DE ANTICONCEPTIVOS)

My Birth Control method is: / (Mi forma anticonceptiva es): _______________________________________________

The dates of my last menstrual cycle / (la ultima fecha menstrual es:) _________________ to ____________________.

Consent: I have answered all the questions to the best of my knowledge and understand the information presented is correct. I have also informed the technologist that I am NOT pregnant at this time. Patient /Parent/Legal Guardian Signature: ___________________________________ DATE: ____________ (FIRMA) (FECHA) FOR CLINICIAN USE ONLY: TECHNOLOGIST SIGNATURE: ______________________________ Patient Shielded? Yes / No / N/A