CT Scan Questionnaire

📋 Patient information

LAST NAME :

FIRST NAME :

Date of birth :

Weight :

Height :

Address :

Home phone * :

Mobile * :

Email * :

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

GP / Referring physician :

Limited mobility (wheelchair, stretcher) :

YES NO

Ambulance arranged :

YES NO

⚠️ Please read each question carefully and correct if needed.

♀ For women only

Are you pregnant or could you be pregnant?

⚠️ If yes, a pregnancy test is required before the CT scan.

YES NO

⚕️ Allergy screening

Iodine allergy?

YES NO

Other allergies (pollen, medications…)?

YES NO

Allergic reactions (hives, eczema, asthma, angioedema…)?

YES NO

🩸 Diabetes screening

Do you have diabetes?

YES NO

If yes, are you taking an oral antidiabetic medication?

Metformin, Januvia, Jardiance…

⚠️ If yes, remember to stop this medication for 48 hours after the scan.

YES NO

💊 Blood thinner screening

Are you taking an antiplatelet agent?

Aspirin, Plavix, Clopidogrel…

YES NO

Are you taking an anticoagulant?

If yes, which one:

YES NO

If necessary, a remote radiologist may be consulted.
In this case, I give my consent to Dr MORALES to use teleradiology for the interpretation of images taken during my examination.

✍️ Patient declaration

Full name :

Date :

Signature :

Please rotate your phone

CABINET TESLA — MEDICAL IMAGING CENTER

Cognac Clinic • Dr Pierrick MORALES