Calcium Score Questionnaire

🪪 Patient identity

LAST NAME :

FIRST NAME :

Date of birth :

Age :

Phone * :

Address :

Email * :

* Required: a 10-digit phone number and a valid email address.

❤️ About your examination

You are going to have a calcium score CT scan, a non-invasive imaging technique that measures the extent of calcium deposits in the coronary arteries.
Please complete this document carefully and follow the recommendations closely.

🩺 Medical information

Are you a smoker?

YES NO

Do you have a pacemaker?

⚠️ Please inform the medical team immediately.

YES NO

Do you have diabetes?

YES NO

Do you have high cholesterol?

YES NO

📏 Measurements

Weight : kg

Height : cm

⚠️ Pre-examination recommendations

If you have a hairy chest, please shave the areas indicated on the diagram below (for electrode placement).
Do not drink tea or coffee in the hours before the examination.

✍️ Patient declaration

I certify that I have personally completed this form, have read and understood its content, and give my consent for the examination to be carried out.

Full name :

Date of birth :

Date :

Signature :

Please rotate your phone

CABINET TESLA — MEDICAL IMAGING CENTER

Cognac Clinic • Dr Pierrick MORALES