X-Ray Patient Pre-Screening Form
Name Phone E-Mail Date & Location Of Exam Appointment Time Referring Physician Type of Exam Date Date of Birth Age Social Security# Height Weight Male Female Reason for Exam
Name Phone E-Mail Date & Location Of Exam Appointment Time Referring Physician Type of Exam Date Date of Birth Age Social Security# Height Weight Male Female
Reason for Exam
Have You Had Any Type Of Surgery? Yes No
If Yes, please list all procedures and dates.
Pacemaker/Valve Implanted electrical device Metal in Eyes Ear/Cochlear implant Neurostimulators Tissue Expander Brain/aneurysm clips Stents Braces Metal fragments or shrapnel Magnetic dental implants Orthopedic Joints / Screws Filters or wire blood vessels
If known, please give name and date of implant
Have You Ever Worked With Any Type Of Metal? Yes No
Are you Pregnant? Yes No Are you breastfeeding? Yes No
Patient Name Date
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