Patient History Form for CT Scan

Please complete the following form before your CT Scan with AMI:

PATIENT INFORMATION
Appointment Date: Name Date of Birth
Phone (Home) Phone (Work) Phone (Cell)
Address City, State Zip
Emergency Phone Gender Weight
Email:        
Check this box if you normally take Glucophage - but understand that none will be taken 48 hours after this exam  
PATIENT HISTORY
History of allergy to drugs If yes, please specify:
History of allergy to contrast media If yes, please specify (type of reaction):
History of allergies, other than drugs      
History of asthma   Last attack (if any):
Prior Iodinated (CT/IVP) contrast injection within the last 72 hours  
Hypertension or Hypotension  
Diabetes   Specific (if known):
Multiple Myeloma        
Congestive Heart Failure        
Kidney/Renal Failure        
Respiratory Failure