POSITRON EMISSION TOMOGRAPHY PATIENT MEDICAL INFORMATION
FORM
Makati PETCT Center @ Centuria
COMPLETELY FILL IN THE FORM. WRITE ''N/A'' IF NOT APPLICABLE. ONCE COMPLETED, SEND THIS TO PET/CT STAFF AT
[email protected]
PATIENT DATABASE
NAME (Last, Given, Middle) DATE OF BIRTH AGE/SEX MARITAL
STATUS
REQUESTING PHYSICIAN
Hospital where you consulted PLACE OF BIRTH
ATTENDING PHYSICIAN
ADDRESS (Number/Unit, Building, Street, Barangay, Town/City, Province, Country, Area Code)
CONTACT NUMBER(S)
EMAIL
OCCUPATION
NATIONALITY
RELIGIOUS AFFILIATION
PERSON TO NOTIFY IN CASE OF EMERGENCY
NAME RELATIONSHIP
CONTACT
ADDRESS NUMBER
MEDICAL HISTORY
DIAGNOSIS PET/CT SCHEDULE
HISTOPATHOLOGY RESULT DATE
DATE TIME
REASON FOR PET/CT REQUEST
SURGICAL HISTORY (Please indicate the TYPE OF SURGERY and DATE)
PET/CT PROTOCOL
BLOOD TESTS (Please Indicate TYPE and DATE)
PREVIOUS IMAGING STUDIES (XRAY, Ultrasound, CT, MRI, PET, Bone Scan, etc., Please indicate TYPE, DATE and HOSPITAL)
CHEMO THERAPY (Please indicate START and END Date of Treatment and NUMBER OF SESSIONS)
RADIO THERAPY (Please indicate START and END Dates of Treatment and NUMBER OF SESSIONS)
ALTERNATIVE MEDICINE (Chinese, Herbal, Alternative healing, Please Indicate Type and Duration/Frequency of Treatment)
GCSF INJECTIONS (Please indicate the Drug and the DATE of Injection)
CURRENT MEDICATIONS (Please indicate DRUG and DOSE and ADMINISTRATION DETAILS)
LAST MENSTRUAL PERIOD (Please indicate the DATE of FIRST DAY)
PREGNANT or BREAST FEEDING
Are you DIABETIC? Medications for DIABETES?
Are you HYPERTENSIVE? Medications for HYPERTENSION?
Type of Thyroid
Do you have Thyroid Disease? Last intake of LEVOTHYROXINE?
Disease
History/ Current PULMONARY TUBERCULOSIS Infection (Please indicate DATE of Infection)
Smoker?
Since When?
Allergies to Drugs, Food, and Others. (Please indicate Reaction to allergy, and last attack)
Are you currently having an allergic attack? Since When?
Do you have asthma? Medication for Asthma:
Are you in pain? (Please grade the INTENSITY of the pain 1-10 with 10 being the most painful, indicate LOCATION and DURATION)
Do you need to be SEDATED for the procedure? (Due to pain, uncontrolled movements, claustrophobia, etc..)
Do you have MEDICAL/COSMETIC implants? (Please indicate LOCATION and date of Implantation)
Do you have any medical condition(s) that you want us to be aware of?
PATIENT'S SIGNATURE /DATE/ TIME INTERVIEWER /DATE /TIME
ANY OF THE FOLLOWING IN THE LAST TWO WEEKS?
EXPOSURE HISTORY YES NO REMARKS
International Travel in the last weeks
Local travel (community with local
transmission)
Close contact with confirmed COVID-19 case (direct care /
same
closed environment / travelling in close
proximity)
Consulted in another hospital for COVID-19 symptoms? When?
Where?
CLINICAL SIGNS & SYMPTOMS
Fever (Temp >/=37.5 C)
Symptoms of URTI (sore throat,
colds)
Cough
Difficulty of breathing
Diarrhea
Non-disclosure of truthful data can lead to CANCELLATION of your procedure even when you have already arrived
Note: in our center.
Thank you for your cooperation.
