Radiation Exposure History Form
Please provide your radiation exposure history and any related medical details so the information can be reviewed accurately.
Patient Identification
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
Radiation Exposure History
Primary source/type of radiation exposure
*
Please Select
Medical imaging
Occupational equipment/source
Industrial source
Environmental exposure
Accidental spill/release
Unknown
Other
Approximate date of exposure
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exposure frequency or duration
Exposure setting and relationship
*
Please Select
Occupational
Medical
Accidental
Environmental
Unknown
Immediate symptoms or known health effects
Medical Follow-up and Notes
Prior related imaging or radiation treatment history
None
X-ray
CT scan
MRI
Ultrasound
Nuclear medicine study
Radiation therapy
Other
Protective measures used
Lead apron
Thyroid shield
Dose optimization discussed
Shielding provided
Not sure
Other
Submit
Should be Empty: