CT PATIENT HISTORY
Phone: 713.425.8100 • Fax Orders: 713.425.8182
q 2600 N. Gessner, Ste. 150, Houston, TX 77080
q 5630 E. Sam Houston Pkwy N., Houston, TX 77015
q 1336 Pin Oak Road, Katy, TX 77494
Patient name: ___________________________________________________________________________________________________
Date: _______/_______/___________ Type of exam: CT ___________________________________________________________
Weight: ________ Height: ________ (Female patients)
: Are you pregnant, or suspect you may be pregnant? q Yes q No
When is your next follow up appointment with your doctor? ________________________________________________________
Explain present condition (How and When you were injured? Where is your pain, and for how long?):
Do you have or have you had any of the following:
Rheumatoid Arthritis/Scleroderma q Yes q No
Please list any other medical conditions not listed above:
List any and all past surgeries and the year they were done:
Have you had any previous imaging studies related to today’s procedure?
If yes, please list type of study, date and location:
If yes, do you take any medications containing metformin such as Glucophage, Glucovance, Avandamet, Janumet, or Metaglip?
If you are taking any of the medications listed above, it must be withheld for 48 hours following the exam. Did your Doctor instruct you to do this?
If yes, please list:_____________________________________________________
Have you had intra-venous iodine injected into a vein? q Yes q No If yes, please check if you had:
Contrast type: ________________________ Amount injected: __________________________ Amount wasted: _________________________
Exp Date: _____________________________ Lot: ______________________________________ # of IV attempts: _________________________
q Yes q No Injection site: _____________________________ Injection time: __________________________
q Yes q No Post-proc instructions given? q Yes q No
Completed by: ________________________ Date: _____________________________________ Time: __________________________________
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T O N Y W I G H T G A L L E R Y 845 West Washington Boulevard | Chicago 60607 | t. 312.492.7261 | [email protected] Dannielle Tegeder American, b. 1971 Lives and works in New York EDUCATION MFA School of the Art Institute of Chicago BFA State University of New York at Purchase Amsterdam School of Fine Arts, The Netherlands Arrangements to Ward Off Accidents, Priska C. Juschka Fine
Obsessive-compulsive Disorder (OCD) Dr. Mohammed Sadiq An increasing number of obsessive-compulsive disorders are surfacing among Muslim communities around the world. This article is intended to provide some information about OCD to those who are suffering from this disorder. As such, the symptoms of this disorder, some contributing factors as well as some treatment alternatives will be dis