NRad PET Appointment Questionnaire

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Height (cms) *

Weight (kgs) *

Are you claustrophobic? *

YesNo

Have you had a previous PET scan? *

YesNo

Please indicate where and when you had your PET scan/s: *

Have you had a previous CT or MRI scan? *

YesNo

Please indicate where and when you had your CT or MRI scan/s: *

Any recent surgery including biopsies in the last 3 months? *

YesNo

Please specify what part of the body and type of operation or biopsy: *

Are you diabetic? *

YesNo

If YES, is your diabetes:

Diet controlledTablet controlledInsulin controlled

Have you had a recent blood test with eGFR? *

YesNo

If YES, where and when did you have this blood test? *

For PSMA Scans: Have you had a recent blood test with PSA? *

YesNo

If YES, what is the PSA score: *

Please list any other medical conditions: *

Please provide a list of medications (including tablets and injections): *

Do you have a follow-up appointment with your doctor? *

YesNo

Date and time of your follow up doctors appointment: *

Are you or could you be pregnant? *

YesNoMaybe/unsure

Are you breastfeeding? *

YesNo

When you are having blood taken - does the nurse have trouble finding a vein? *

YesNo

I confirm that I have answered the above questions and that the information is true and correct.

Patient/Guardian Signature *

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Today's date *

For security please complete the check below *