THE MOUNT SINAI HEALTH SYSTEM Name: GPSThere Mount Stnai Mount Sinai Mount Sinai
THE MOUNT SINAI HEALTH SYSTEM Name: GPSThere Mount Stnai Mount Sinai Mount Sinai
Hospital West Beth lsrae:
Mount Sinai Mount Sinai Mount Sinai Queens St. bake's Brooklyn New York Mount Sinai
Eye and Ear Outpatient
Infirmaryat Faculty
MountSinai Practices
RADIOLOGY OUTPATIENT
ASSESSMENT QUESTIONNAIRE Date of Birth: /74) / S3 Gender:
Medical Record Number (if known):
Requesting Physician:
Today's Date: 17/ I S / 1 co
MEDICAL HISTORY:
1. Please indicate the reason you are
having this exam (why did your
doctor order this test?):
2. Please list any known diagnosis or describe any Injury, pain or
other symptoms related to this exam:
3a. Also, what specific part of your body Is affected (location & side)?
3b. How long you have had symptoms (duration)?
3. If you have ever had cancer, please
indicate type and year diagnosed:
4. Please list any previous surgery or
treatment (including radiotherapy)
related to the reason you are
having this exam:
S. Have you had a nuclear medicine Injection in the past 7 days, such as for bone scan or thyroid? a No ❑ Yes
Sa. If yes, what type of Injection/scan, and what date did you receive it?
6. Before today, have you
had any radiology study
of the area being
examined now? oNo
o Yes 4 When?
What type (X-ray, ultrasound, CT, MRI, etc.)?
Were prior exams at one of these Mount Sinai Health System sites?
❑ Mount Sinai Hospital
o Mount Sinai St. Luke's
o Mount Sinai Brooklyn (formerly Kings
Highway/Beth Israel Brooklyn)
a Another Mount Sinai-affiliated imaging center: Mount Sinai Beth Israel
c Mount Sinai West (formerly Roosevelt)
r. New York Eye & Ear Infirmary at
Mount Sinai
FOR FEMALE PATIENTS OF REPRODUCTIVE AGE (11-50 YEARS):
7. To the best of your knowledge, are you pregnant or do you think you could be? ❑ Yes c0. No C Possible/unsure
8. If you may be pregnant or are unsure, indicate the start of your last complete menstrual period:
FOR ALL PATIENTS, PLEASE SIGN BELOW:
9. Please print name,
sign, date and time PRINTED
SIGNATURE zPatient a Friend
c Pelat ve ❑Other:
DATE TPAE
Four to RAD-1002 (Revised 101612016)
EFTA00313613