CT Scan History Form

Yes
No
Have you had a previous imaging study that required an injection of contrast media?
If yes, did you experience any difficulties for the contrast injection?
Hives
Rash
Difficulty Breathing
Other
**If you experienced any of the above and your exam was ordered with contrast please contact our office to discuss.**
History of kidney disease

Do you have any of the following?

Asthma/hay fever
Allergies to latex
*Please notify our staff if you have a known allergy to latex so that we may use the appropriate gloves and tape.
Congestive heart failure
Diabetes
Fibrillation and/or fluter of the heart
Heart disease or heart problems
Hypertensive heart disease (high blood pressure)
Myocardial infarction (heart attack)
Multiple myeloma
Respiratory failure
Severe arrhythmia (irregular heart beat)
Sickle cell disease
Stroke
Tachycardia (an abnormally high heart rate)
Angina pectoris (severe constricting pain in chest)

Please list ALL of your allergies below (medicine, food, other):





Please list ALL medications you are currently taking below: