Patient Screening Form
Patient Information
Name:_____________________________________________________________ Body part to be examined:______________________________________________________ Reason for exam and/or symptoms:_______________________________________________________________________ How long have you had symptoms?_______________________________________________________________________ Medical Information
1. Have you had a reaction to a contrast medium or dye used for imaging? Yes If yes, have you been premedicated? Yes 2. Have you had a prior imaging study (MRI, CT, Ultrasound, X-ray, etc.)? 3. Have you had a prior cystoscopy or endoscopy? Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ 5. Do you have:  diabetes  vasculitis  high blood pressure  renal disease/disorder  multiple myeloma  pheochromocytoma  heart disease/disorder  lupus  respiratory disease  sickle cell anemia/trait  congestive heart failure (CHF)  systemic lupus erythematosus (SLE)  liver failure  allergies ______________________ ____________________ _________________________ _____________________ ____________________ _________________________ 6. Do you take Actoplus Met, Avandamet, Diaben, Diabex, Diaformin, Fortamet, Glucophage, Glucovance, Gluformin, Glumetza, Janumet, Kombiglyze, Metaglip, Metformin, Obimet, Prandimet, or Riomet? Yes 7. List current or recently taken medication and doses:_______________________________________ Unknown ________________________________________________________________________________ 8. Are you a smoker or a former smoker? Yes 9. Do you have a personal history of cancer? If yes, describe type:_______________________________________________________________ Describe current or past treatments: (i.e. radiation or chemotherapy) _________________________ Date of treatment: _________________________________________________________________ 10. Please list any additional information you feel pertinent to today's exam:_______________________ ________________________________________________________________________________ **Please complete and sign back of form**
Form # CL072A Revised: 09-01-13
For Female Patients Only
1. Date of last menstrual period: __________________________ 2. Are you pregnant or experiencing a late menstrual period? If yes, was it a complete hysterectomy? (removal of ovaries and uterus) Date of surgery:____________________________________ 4. Are you taking oral contraceptives or receiving hormonal treatment? Staff Use Only

Staff Notes:_____________________________________________________________________________________________
______________________________________________________________________ Staff Signature:_____________________________________________ Date:_____________________________________
Medical Records Release
_____________________________________________________________________________________________ Please sign the medical release below.
This allows our facility to obtain your previous exams or prior medical history as it pertains to today’s exam.
_______________________________________________________ _______________________________________________________ _______________________________________________________ Patient Name:_________________________________________________________________________________________ Social Security #:_____________________________________ Date of Birth:________________________________ Type of records requested:_______________________________________________________________________________ I hereby authorize and request you to release the complete medical records mentioned above, including copies of the reports in your possession to Diagnostic Imaging Centers, PA. ___________________________________________________ ___________________________________________ Patient or Authorized Person Patient Signature
Patient Signature____________________________________ Date__________________________________________
Technologist________________________________________ Technologist___________________________________

5400 North Oak • Kansas City, MO 64118 • 816-455-5959 4911 S. Arrowhead Drive, Suite 100 • Independence, MO 64055 • 816-795-7040  301 NE Mulberry, Suite 100 • Lee’s Summit, MO 64086 • 816-554-0040 13795 S. Mur-Len Rd, Suite 100 • Olathe, KS 66062 • 913-397-7272 5500-5520 College Blvd. • Overland Park, KS 66211 • 913-491-9299 4801 Main, Suite 200 • Kansas City, MO 64112 • 816-561-5151 Form #CL072B Revised: 09-01-13

Source: https://www.dic-kc.com/Forms/Patient-Screening-Form.pdf


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