EFTA00313613.pdf

THE MOUNT SINAI HEALTH SYSTEM Mount Stnai Mount Sinai Mount Sinai New York Mount Sinai Name: GPSThere Hospital West Beth lsrae: Eye and Ear Outpatient Mount Sinai Mount Sinai Infirmaryat Faculty Queens St. bake's Mount Sinai Brooklyn MountSinai Practices Date of Birth: /74) / S3 Gender: Medical Record Number (if known): RADIOLOGY OUTPATIENT Requesting Physician: ASSESSMENT QUESTIONNAIRE Today's Date: 17/ I S / 1 co MEDICAL HISTORY: 1. Please indicate the reason you are having this exam (why did your doctor order this test?): 2. Please list any known diagnosis or describe any Injury, pain or other symptoms related to this exam: 3a. Also, what specific part of your body Is affected (location & side)? 3b. How long you have had symptoms (duration)? 3. If you have ever had cancer, please indicate type and year diagnosed: 4. Please list any previous surgery or treatment (including radiotherapy) related to the reason you are having this exam: S. Have you had a nuclear medicine Injection in the past 7 days, such as for bone scan or thyroid? a No ❑ Yes Sa. If yes, what type of Injection/scan, and what date did you receive it? 6. Before today, have you oNo had any radiology study of the area being o Yes 4 When? examined now? What type (X-ray, ultrasound, CT, MRI, etc.)? Were prior exams at one of these Mount Sinai Health System sites? ❑ Mount Sinai Hospital Mount Sinai Beth Israel o Mount Sinai St. Luke's c Mount Sinai West (formerly Roosevelt) o Mount Sinai Brooklyn (formerly Kings r. New York Eye & Ear Infirmary at Highway/Beth Israel Brooklyn) Mount Sinai a Another Mount Sinai-affiliated imaging center: FOR FEMALE PATIENTS OF REPRODUCTIVE AGE (11-50 YEARS): 7. To the best of your knowledge, are you pregnant or do you think you could be? ❑ Yes c0. No C Possible/unsure 8. If you may be pregnant or are unsure, indicate the start of your last complete menstrual period: FOR ALL PATIENTS, PLEASE SIGN BELOW: 9. Please print name, zPatient a Friend sign, date and time PRINTED c Pelat ve ❑Other: SIGNATURE DATE TPAE Four to RAD-1002 (Revised 101612016) EFTA00313613