Radiology Pre-Procedure Screening

Radiology Pre-Procedure Screening — Form Fields

This healthcare template includes 10 fields. Screen a patient before a radiology procedure for contraindications such as metal implants or allergies. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Exam Ordered (text, required)
• Ordering Physician (text, required)
• Do You Have Any Metal Implants or Devices? (multiple choice, required) — options: Yes, No, Not Sure
• If Yes, Please Select All That Apply (checkboxes, optional) — options: Pacemaker, Neurostimulator, Cochlear implant, Aneurysm clip, Joint replacement, Other metal implant
• Do You Have Any Known Allergies to Contrast Dye? (multiple choice, required) — options: Yes, No, Not Sure
• Are You Pregnant or Possibly Pregnant? (multiple choice, required) — options: Yes, No, Not Applicable
• Weight (lbs) (text, optional)
• Additional Medical Information (long text, optional)