CT Exam Preparation Checklist
Please complete this checklist to ensure you are ready for your upcoming CT scan.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date and Time of CT Exam
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of CT Exam
*
Please Select
Head
Chest
Abdomen/Pelvis
Spine
Other
Have you had anything to eat or drink in the last 4 hours?
*
Yes
No
Do you have any allergies, especially to contrast dye or iodine?
*
Yes
No
Are you currently pregnant or possibly pregnant?
*
Yes
No
Not Applicable
Are you wearing or carrying any metal objects (e.g., jewelry, implants, hearing aids)?
*
Yes
No
Have you had any previous reaction to contrast dye?
*
Yes
No
List any medications you are currently taking (especially diabetes medications):
Additional Comments or Special Instructions
Signature
*
Submit Checklist
Submit Checklist
Should be Empty: