Services — Southtowns Radiology

Name:

Address:

Telephone: home

office

cell

E-Mail Address:

Date of Birth:

Height:

Weight:

Emergency Contact:

Phone:

How did you hear about us?

Last Menstrual Period:

Date of your last physical exam:

Primary physician's name and phone:

Primary physician's address:

OB/GYN's name & phone:

OB/GYN's address:

Primary Insurance:

Secondary Insurance:

Have you been diagnosed by a medical physician with a Uterine Fibroid?

yes no

Are you pregnant?

yes no

Do you wish to get pregnant?

yes no

Do you have any tattoos in the abdominal region?

yes no

Have you had any abdominal liposuction?

yes no

Have any extensive body piercing?

yes no

Have you had a previous Uterine Artery Embolism (UAE / UFE)?

yes no

Do you have any scars in the abdominal or stomach area?

yes no

Are you claustrophobic?

yes no

If you answered yes to any of the above questions please explain and provide us with any details, such as dates, what body parts are pierced? Is this piercing removable? What scarring was due to, i.e., C-section or sugery?

How would you describe your health?

Medical History

HAVE YOU HAD OR DO YOU HAVE?

Heart Disease

yes no

Diabetes

yes no

Pulmonary Disease

yes no

High Blood Pressure

yes no

Stroke / TIA

yes no

Thromboembolism

yes no

Anemia

yes no

Asthma or Emphysema

yes no

Breast Cancer

yes no

Cervical Cancer

yes no

Any Cancer

yes no

Renal Disease

yes no

Allergies: please list substance & reaction

yes no

Bleeding, clotting or spotting between periods and/or vaginal bleeding (Menorrhagia)

yes no

How far apart are your periods?

How many days is your average period?

Vaginal bleeding which has not been diagnosed

yes no

Painful intercourse

yes no

Abdominal Cramping

yes no

Abdominal Pain or Pressure

yes no

Abnormal PAP results

yes no

History of Pelvic Infections of Endometritis

yes no

Full term delivery

yes no

Premature delivery

yes no

Stillbirth / Miscarriage

yes no

Pelvic Carcinoma or pre-malignant condition

yes no

Pelvic Inflammatory Disease

yes no

Are you considered peri, pre or post menopausal?

yes no

Are you taking any hormone therapy medications?

yes no

Have you used hormone therapy in the past?

yes no

Pain or burning on urination

yes no

Frequent urination, day or night

yes no

Extreme urge to urinate

yes no

Bright red blood in stool

yes no

Diarrhea or Constipation

yes no

Nausea / Vomiting

yes no

Change in bowel habits

yes no

Back Pain

yes no

Any Muscle Pain

yes no

Leg / Ankle Swelling

yes no

Rashes

yes no

Abdominal Laser Hair Removal

yes no

Depression

yes no

Emotional difficulty or difficulty with thinking or problem solving

yes no

Headaches

yes no

Blackouts or Dizziness

yes no

Any Leg(s) Weakness

yes no

Loss of Sensation

yes no

If you answered yes to any of the above questions please explain and provide us with any details below.

Illness & Surgeries

Please list all previous illness and surgeries and the corresponding date, including C-sections.

Please list all medications you take regularly including the frequency and dose.

Please list any allergies you have and if you have ever had any adverse reactions.

This section is to evaluate your symptoms. Please provides us, in your own words, a description of your symptoms related to your menstrual cycle and any problems you have related to your fibroids. For example, how many days, irregular bleeding, is there spotting between cycles, your pain and/or anything else to help us to better understand how you feel. Please note, this procedure is not recommended for women who desire future pregnancies.

SEDATION SCREENING

Are you claustrophobic?

yes no

Do you have any liver or kidney function problems?

yes no

Family History

Family
Member

Health status
please indicate if
family member is
(was) in good health
or poor health

Age

If deceased,
list cause of
death

Comments

Mother

Father

Brother

Sister

Children

Metal Screening For MRI Use

Do you have:

Pacemaker / ACID

yes no

Neurotransmitter

yes no

Aneurysm/brain clips

yes no

Implanted pumps

yes no

History of metal in the eye

yes no

Shrapnel or metal fragments in your body

yes no

Inner eye implants

yes no

Inner ear implants

yes no

IUD

yes no

Pessary Ring

yes no

Tattoos or piercings other than ears

yes no

Download and fill out our Medical Release Form.

Sections

MR-Guided Fibroid Ablation Survey

Medical History

Illness & Surgeries

SEDATION SCREENING

Family History

Metal Screening For MRI Use

Do you have: