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Radiology Pre-Procedure Screening - Free Healthcare Template | ZenBuild | ZenBuild

Templates→Healthcare→Radiology Pre-Procedure Screening

Radiology Pre-Procedure Screening

Screen a patient before a radiology procedure for contraindications such as metal implants or allergies.

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Radiology Pre-Procedure Screening

Screen a patient before a radiology procedure for contraindications such as metal implants or allergies.

Patient Full Name*

Date of Birth*

Exam Ordered*

Ordering Physician*

Do You Have Any Metal Implants or Devices?*

YesNoNot Sure

If Yes, Please Select All That Apply

PacemakerNeurostimulatorCochlear implantAneurysm clipJoint replacementOther metal implant

Do You Have Any Known Allergies to Contrast Dye?*

YesNoNot Sure

Are You Pregnant or Possibly Pregnant?*

YesNoNot Applicable

Weight (lbs)

Additional Medical Information

Template Details

CategoryHealthcare

IndustryHealthcare

Fields10

Uses0

Views2

radiologyscreeningMRIcontrast