CT Request – Neck / Spine

Brandywine
Omega Imaging
Pike Creek
Glasgow

Patient Number:
Date: xx/xx/xxxx
First Name: Middle: Last:
Birthdate: xx/xx/xxxx      Age:     
Email Address:
  
Requesting Doctor:
Family Doctor:

Why do you need this test?


Possibility of being pregnant? yes no
If yes, Last Menstuation Period? xx/xx/xxxx


Clinical Information
Check if yes

Neck mass     Left     Right
Neck pain     Left     Right
Neck swelling     Left     Right
Pain/numbness in arm     Left     Right
Upper Back Pain     Left     Right
Lower Back Pain     Left     Right
Leg pain, which side?     Left     Right
Leg numbness, which side?     Left     Right
Cold leg/foot, which side?     Left     Right
Cramp when walking     Left     Right


SPINE OR NECK INJURY (give details if known)
Neck or Back injury: yes no     Date:     Place:

Additional Pertinent Information:


Any known Tumor: yes no     What part of the body
Any other Surgery: yes no     What part of the body

Allergies: yes no     Type:
Heart Problems: yes no
Kidney Problems: yes no
Asthma: yes no
Allergy to x-ray dye: yes no


Previous Examinations:
(give dates and places if known)

MRI of Spine   Date: Where:
CT of Spine   Date: Where:
Spine X-Rays   Date: Where:
Myelogram   Date: Where:
Nuclear Medicine Scan   Date: Where:
E.M.G.   Date: Where:
Others, specify: Date: Where:




Technologist: ,RT