[wr_row width=”boxed” background=”none” solid_color_value=”#FFFFFF” solid_color_color=”#ffffff” gradient_color=”0% #FFFFFF,100% #000000″ gradient_direction=”vertical” repeat=”full” img_repeat=”full” autoplay=”yes” position=”center center” paralax=”no” border_width_value_=”0″ border_style=”solid” border_color=”#000″ div_padding_top=”10″ div_padding_bottom=”10″ div_padding_right=”10″ div_padding_left=”10″ ][wr_column span=”span12″ ][wr_heading el_title=”CT Questionnaire” tag=”h2″ text_align=”center” heading_margin_top=”25″ heading_margin_bottom=”25″ font=”inherit” enable_underline=”yes” border_bottom_style=”solid” appearing_animation=”0″ disabled_el=”no” ]CT Questionnaire[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] NAME Date WEIGHT FEMALE PATIENTS: PREGNANT YN BREAST FEEDING YN REASON FOR EXAM HOW LONG HAVE YOU HAD THE ABOVE SYMPTOMS? ANY PREVIOUS IMAGING OF THE BODY PART BEING EXAMINED TODAY? YN IF YES, WHERE? WHEN? PLEASE LIST ALL PRIOR SURGERIES HAVE YOU EVER RECEIVED IV CONTRAST/XRAY DYE? YN IF YES, DID YOU HAVE AN ALLERGIC REACTION? YN IF YES, DESCRIBE THE REACTION: DO YOU CURRENTLY HAVE OR HAVE YOU HAD A HISTORY OF: KIDNEY DISEASE/DIALYSIS: YN LUNG DISEASE: YN HAYFEVER: YN HIVES: YN HEART DISEASE: YN MULTIPLE MYELOMA: YN SICKLE CELL DISEASE: YN SMOKING: YN CANCER: YN DIABETES: YN RADIATION/CHEMO: YN DO YOU TAKE ANY MEDICATIONS CONTAINING METFORMIN: YN DATE OF LAST TREATMENT: [/wr_text][/wr_column]
