Medical History Form

Helps our radiologists provide the safest and most accurate imaging study for you.

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1. Patient Information

Full Name *

Date of Birth *

Exam Ordered

Primary Care Physician

2. Medical Conditions

Check all that apply to you:

Other conditions not listed above:

3. Allergies

Do you have any known allergies to the following?

Iodine or iodine-containing foods (shellfish)Contrast dye (prior reaction to IV dye)Latex / rubberMedications (specify below)Food allergies (specify below)

Allergy details / reactions experienced:

4. Current Medications

List all current medications, supplements, and vitamins:

Are you currently taking Metformin (Glucophage)?

Yes No

Note: If you are taking Metformin and require contrast dye, you may need to hold this medication before and after your exam. We will advise you when scheduling.

5. Recent Lab Work (Contrast Studies)

If your exam involves IV contrast (dye), recent kidney function labs may be required.

Creatinine (most recent)

eGFR (if known)

Lab Date

6. Surgical & Imaging History

Prior surgeries or procedures (most recent first):

Prior imaging at another facility for same area/condition:

7. Certification

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that providing accurate medical history allows our team to provide me the safest and most appropriate imaging study.

Patient Signature *

Sign above

Date

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