[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=”XRAY 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” ]XRAY QUESTIONNAIRE[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] Name Date Patient telephone number: When is your next doctor’s appointment? Reason for exam today? How long have you had the above mentioned symptoms? List any surgeries in the area being examined today Medical History: (circle all that apply) Diabetes YN Asthma YN COPD YN Emphysema YN High Blood Pressure YN Heart Disease YN Smoking (past or present) YN Cancer: Type Is this a workers comp injury? YesNo Is this a result of an auto accident? YesNo If yes what is the date of injury: Females only: Are you or could you be pregnant? Have you had prior imaging of the area being imaged today? YesNo WHERE WHEN Additional Tech Notes: Referring Clinician: Telephone number [/wr_text][/wr_column][/wr_row]