PET/CT
CLINICAL QUESTIONNAIRE
Name: _______________________________________ Date:
Allergies
1. Why has your doctor sent you for this test? Did he/she give you a specific diagnosis?
____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________
2. Please describe what specific complaints/symptoms have been most bothersome to you?
_______
_______
_______
3. How long have you had these complaints/symptoms? _________________________________
4. Did these complaints/symptoms come on suddenly or gradually? ________________________
5. These complaints/symptoms have: ____improved ____remained the same ____worsened
6. Have you had any previous surgery related to today’s exam? ________Yes _______No
(If yes, type and date: __________________________________________________________
7. Have you had any prior tests related to today’s exam?
MRI Date: _________ Place: _________________________
CT Scan Date: _________ Place: _________________________
Ultrasound Date: _________ Place: _________________________
Nuclear Medicine Date: _________ Place: _________________________
Other_______________________________________________________________
What were the results of these tests? __
Female patients only:
Are you pregnant? Y / N Last menstrual period: __________
WORD/FORMS/CLINICAL QUESTIONNAIRES/PET 6/3/2020
*******FOR STAFF USE ONLY******
PET / CT PATIENT INFORMATION WORKSHEET
NAME:__________________________________________ DATE:__________________________
ADDRESS:_______________________________________________________________________
DOB:______________________ PT ID: __________________ ACCESSION#: _________________
DIAGNOSIS: ________________________________ Ordering Physician: ____________________
CLINICAL HISTORY: Chemo ___________________________________________________
Surgery ___________________________________________________
Rx Tx ____________________________________________________
Pre-Injection: 18 FDG _________________ mCi Time: ____________________
Injection: 18 FDG _________________ mCi Time: ____________________
Post-Injection: 18 FDG _________________ mCi Time: ____________________
Site of Administration: ______________________________Scan Start Time:_____________________
Diabetic: Y N NPO 4-6hrs: Y N Caffeine: Y N Strenuous Exercise: Y N
Infiltrate: Y N Sex: M F LMP:________________Breast Feeding: Y N
Height: ____________________ Comments:______________________________________
Weight: ___________________ _______________________________________________
BGL: ______________________ _______________________________________________
Pain Level: _________________ _______________________________________________
PHYSICIAN ORDER CHECKED (INJECTING TECH SIGNATURE)____________________________________
WORD/FORMS/CLINICAL QUESTIONNAIRES/PET 6/3/2020
Informed Consent
I, _____________________________________________, authorize Northeast Radiology or its
associate to perform a Positron Emission Tomography (P.E.T.) / Computerized Axial
Tomography (C.A.T.) scan. I understand that this test will give my physician information about
the metabolic and physiologic activity of my body or organs. I understand that it will be
necessary to check my blood sugar level prior to the scan and that a temporary intravenous line
will be started in my arm or hand vein. The procedure has been explained to me and I
understand that I will be injected through this I.V. line with a radioactive isotope, 18F-FDG
(fluorodeoxyglucose). 18F-FDG is a radiolabeled analog of glucose that is rapidly distributed to
all organs of the body. There are no known adverse reactions or allergies associated with the
injection. I have had an opportunity to review this form and to ask questions. My questions
have been answered to my satisfaction. I certify that I have read the preceding information and
that I understand it. My consent to this procedure is voluntarily given.
_____________________________________________________ __________________
Patient Signature Date
_____________________________________________________ __________________
Witness Signature Date
Northeast
----==-·--====--==- rffology
Current Medications List
Name: _______________ DOB_____________
Include prescriptions, over the counter, herbal and vitamins.
Name of Medication Strength and Condition Medication Taken
Frequency For
Allergies Reactions
SIGNATURE DATE
Please use back of the form any additional medications.
WORD/FORMS/MEDS AND ALLERGIES 01/22/2019
� Northeast
�Radiology
OUT-PATIENT FALL RISK ASSESSMENT
PATIENT NAME: ------------------- DATE: ---------
DATE OF BIRTH: _______ SITE NAME: ______________
INTERVIEWER NAME: CUSTOMER NUMBER: ---------
Patient: The following questions are intended to identify patients who may be at risk of falling and to help
avoid potential injury. This procedure has been implemented to ensure your safety and to enable us to
provide you with the best possible patient care.
Please circle the appropriate answer to each question below. Our staff will go over these questions with you
prior to your examination to address any questions or concerns you may have.
1. Have you fallen recently (within the last 3 months)? YES NO
2. Do you use a cane, walker or other device to help you walk? YES NO
3. Do you require assistance to stand up? YES NO
4. Have you taken any medications today for anxiety or to relax you? YES NO
If yes, what medication? Dosage Time
5. Are you dizzy, lightheaded, weak in your legs or unable to see or hear clearly? YES NO
Team Member: If the patient, patient's family member or caregiver answers "yes" to any of the above questions, transport the
patient via wheelchair to the imaging system or exam/treatment room.
All patients must be assessed for falls risk prior to transporting patients from the waiting area. The entire form
must be completed signed and retained in the patient's medical record whenever a patient refuses a wheelchair.
Mobile Units Only- The top portion of this document must be completed and retained in the patient's medical record whenever a
mobile units lift or roll/slide door is inoperable and the units stairs must be utilized. If any "yes" answers are provided, the patient
may not utilize the mobile unit stairs and must reschedule for a time when the lift/roll/slide door is operable.
RELEASE OF LIABILITY
Notwithstanding the evaluated risk of fall and Alliance's offer/recommendation to use a
wheelchair for transport to/from the imaging system or exam/treatment room, I decline the use
of a wheelchair. By declining the use of wheelchair for transport to/from the imaging system or
exam/treatment room, I agree, acknowledge and assume all inherent risk including but not
limited to the risk of falling, personal injury, damage to personal property, or otherwise. I, on
behalf of myself, heirs and/or representatives, do hereby waive and agree to release and hold
harmless Alliance HealthCare Services, Inc., its officers, agents, subsidiaries and employees from
any and all liability for any damage, claim or injury to myself or my property or otherwise.
PATIENT SIGNATURE: _____________________ ____
WITNESS SIGNATURE: ____________ TITLE: __________
WORD/ALLIANCE/SAFETY/ PT FALL RISK ASSESSMENT 02/25/2019
