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CT Sinus Patient Information Form

Patient Information

Appointment Date*
Patient Name*
Date of Birth*
in pounds
Sex*

Medical Information

1. Have you had prior head or sinus surgery?*
If yes, please indicate the type and date of head or sinus surgery:
Date of surgery
2. Have you had a prior head or sinus examination (MRI, CT, X-ray, etc.)?*
3. Do you have a history of cancer?*
Smoking status*

For Female Patients Only

1. Date of last mentrual period*
Post Menopausal?*
2. Are you pregnant or experiencing a late menstrual period?*
3. Have you had a hysterectomy?*
If yes, was it a complete hysterectomy? (remo val of ovaries and uterus)
Date of surgery
4. Are you taking oral contraceptives or receiving hormonal treatment?*
5. Are you currently breastfeeding?*

Patient Signature

I attest that the above information is correct to the best of my knowledge. I understand the contents of this form and had the opportunity to ask questions regarding my MRI procedure.

Use your mouse or finger to draw your signature above
Date*
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