Exam:
TOMOGRAPHY
Type:
FT 03-003 - INSTRUCTIONS FOR ALLERGIC PATIENTS
Name:
Phone:
Age:
Date:
Answer the questions writing
"yes"
or
"no"
:
1. Do you have any known disease?
no
yes
don't know
Which one?
2. Are you diabetic?
no
yes
don't know
Do you take any medication?
no
yes
don't know
3. Have you been diagnosed with bronchitis, asthma or allergic rhinitis?
no
yes
don't know
4. Do you have any alergies?
no
yes
don't know
Which one?
5. Are you allergic to shrimp, fish or seafood?
no
yes
don't know
Which one?
6. Are you allergic to any medication or food?
no
yes
don't know
Which one?
7. Are you allergic to sulfa or penicillin?
no
yes
don't know
Which one?
8. Did you have any kind of allergic reaction to medicines with iodine?
no
yes
don't know
Which one?
9. Have you ever gone under a test which required contrast? Example: ct scan, Catheterization, Arteriography, Urography, Colangiography.
no
yes
don't know
Which one?
10. Have you ever gone under a surgery?
no
yes
don't know
Which one?
11. Have you ever gone under a Quimo?
no
yes
don't know
12. Have you ever gone under a Radiotherapy?
no
yes
don't know
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