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Clarity in Every Scan, Confidence in Every Step

X-Ray History and Screening Form

You can download and print the form, then bring it to your appointment or email it to us in advance. Alternatively, you may fill out the online form directly on our website for your convenience.

Download form

1Patient Information

2Informed Consent For X-ray

3Visitor Screening Questionnaire

Patient Information

First Name

Middle Name

Last Name

Address

Sex

Male

Female

Height

Weight (lbs)

Date of Birth

MM slash DD slash YYYY

Age

Email Address

Mobile phone number

Referring Physician

Are you pregnant

Yes

Last Menstrual Period

Reason you are here toda

Explain your medical problem in detail. (What happened? Where did it happen? How long have you had this problem?)

Do you have pain?

Yes

Where?

Have you had any surgeries in the area(s) that are being imaged today?

Yes

Where?

Have you had a previous exam related to this problem?

Yes

If yes, explain

Do you have any of the following?

Asthma

Allergic Respiratory Disease

Diabetes

Kidney Disease

Cancer

Multiple Myeloma

Prostate Problems

Dizziness

Heart Disease

Stroke

Liver Disease

Seizure Disorder

Bladder Disease

Headaches

Orthopedic Pins/Rods/Screws/Plates/etc.

Please explain for each "yes" above

List all locations of your pain or symptoms on your body

List all locations of any metal in your body

Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that at this time I am pregnant OR NOT pregnant.

Initial

Patient/Parent/Legal Guardian Signature

Date

Informed Consent For X-ray

You have the right to be informed about the diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you may choose to give or withhold your consent to the procedure. If you are pregnant or think that you may be pregnant, please inform the technologist at once. Your physician has requested that we perform x-rays to obtain additional information. This is a diagnostic test that involves x-ray images and a computer to produce an image of internal body parts. Your physician believes an x-ray to be the best diagnostic test for you, considering your symptoms and condition. The benefit of this exam is to assist your physician with a diagnosis.

I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, I (WE) HAVE READ IT OR HAVE HAD IT READ TO ME (US), THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS.

THE PROCEDURES TO BE USED, AND THE RISKS AND HAZARDS INVOLVED, AND I (WE) BELIEVE THAT I (WE) HAVE SUFFICIENT INFORMATION TO GIVE THIS INFORMED CONSENT.

Patient Name Printed

Patient Signature

Date

MM slash DD slash YYYY

Time

Hours

Minutes

AM/PM

Claustrophobic: Y or N

Diabetic: Y or N

HBP: Y or N

Allergic to Iodine: Y or N

Allegergies: Y or N

Surgery

Kidney Problems: Y or N

Pacemaker/Metal /Implants/Pain Pumps/Neurostimulator/Stents:

Does PT have an implant card? Y or N

Visitor Screening Questionnaire

Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N

Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N

Within the past 14 days, I have been sick with a cold or flu: Y or N

Within the past 7 days, I have had a fever: Y or N

Within the last 7 days, I have had nausea and vomiting and/or loss of taste and /or smell: Y or N

Within the last 7 days, I have had diarrhea: Y or N

I now have symptoms of a cold or flu: Y or N

I now have a fever: Y or N

Within the past 14 days, I have been around people who have been or are sick with colds or flu: Y or N

I have been nauseated or have vomited or had diarrhea within the past week: Y or N

I have received the COVID-19 Vaccination: Y or N- If yes, please indicate which arm.

Identification Card: Please upload your picture ID card.

Max. file size: 128 MB.

For inquiries or to book an appointment, fill out the contact form below, and we’ll get back to you as soon as possible.

6306 Gulfton St,
Houston, TX 77081

(346) 487-7037

Mon-Fri: 9AM – 7PM
Saturday: 10AM – 3PM

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