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General History Form
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Sex at birth
*
Male
Female
Other
Height
Weight
Chief Complaint:
*
What body part are we imaging today?
*
Which side?
*
Right
Left
Both sides
What is your pain level?
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Do you have any medical conditions?
Rows
Check all that apply
Heart Disease
Lung Disease (Asthma, COPD)
Kidney Disease
Diabetes
Cancer
Other
Please list any additional medical conditions you have.
Have you had any past surgeries? If so, which type?
Are you currently taking any medications? If so, list them below.
**Please note any usage of blood thinners or diabetes medications.
Do you have any known allergies? If so, list all allergies below.
Have you had any recent imaging? If so, please list when, where, and type of image.
Patient Signature
Parent Signature if Patient is a Minor
Electronic Communications
*
HIPAA Privacy
*
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