First Name
*
Last Name
*
Your date of birth
*
Email Address
*
Are you diabetic?
*
Yes
No
Have you had a previous contrast reaction?
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Yes
No
Are you on Beta Blockers?
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Yes
No
Are you on calcium channel blockers?
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Yes
No
Do you have a pacemaker?
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Yes
No
Have you had a Coronary Arteries Bypass Graft (CABG)?
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Yes
No
Do you have stents?
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Yes
No
Do you have fibrillation or ectopic heart beats?
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Yes
No
Do you have asthma?
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Yes
No
Do you have problems with your kidneys?
*
Yes
No
What is your pulse rate?
*
What is your weight?
*
Please provide a list of your current medications:
*
What is your best phone number for our doctor to call you for a consultation?
*
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