PET/CT SCAN QUESTIONNAIRE FORM
Patient Name
Patient Email
Date of Birth
Today’s Date
Weight
Height
Do you have history of cancer ?
(If yes, please list what type and when was it diagnosed)
Have you been treated with Chemotherapy ?
(If yes, for what type of cancer and when)
Have you been treated with radiation treatment?
(If yes, for what type of cancer when and what type of radiation treatment did you receive)
Have you been treated with immunotherapy?
(If yes, for what type of cancer and what type and when)
Did you have any surgery for your cancer?
(If yes, what type of surgery and when)
Did you have any biopsy in the last 3 months?
(If yes, what was the reason and when)
Did you have any surgery in last 3 months?
(If yes, what type and when)
MEDICATIONS:
Are you taking any diabetic medications?
(If yes, are you on insulin ?)
Other History:
Colostomy
Yes
No
Implants
Yes
No
Indwelling Catheter
Yes
No
Drains /Open wounds
Yes
No
Any history of smoking
Any history of valley fever
COPD/ASTHMA
Any recent (last 6 months) history of infection
Any recent ( last 6 months)history of pneumonia
SKELETON HISTORY:
History
Yes/No
Body Location
When
Fractures
Trauma
Arthritis
Prosthesis
Spine Surgery
Chest Surgery
For Female Patients Only:
Is there any chance that you could be pregnant ?
Are you menopausal ?
Last L.M.P
Are you currently breastfeeding ?
PRIOR IMAGING HISTORY:
Total number of PET Scans you had so far
When
Where
Last CT SCAN
When
Where
Last MRI SCAN
When
Where
Submit
