Trinitas Diagnostic Imaging
415 Morris Avenue, Elizabeth, NJ 07208
908-351-7600 (Phone) | 908-351-4406 (Fax)
www.TrinitasDiagnosticImaging.com

Abdomen Questionnaire

If you're coming to our center for an MRI or CT test, print this page, fill out the form and bring it in with you on the day of your appointment.

 
FIRST NAME
LAST NAME
AGE

WEIGHT   DATE  
LMP
Inpatient   Outpatient Emergency Center
Exam Ordered:
CT   IVP MRI (please check one)
Have you had this test or other x-ray tests requiring an injection of IV Contrast before?
YES   NO
If yes, did you have a reaction to the injection?
YES   NO
Describe the reaction





Do you have any allergies to medications?
YES   NO
List





Do you have:
Diabetes
YES   NO
Blood Disorders
YES   NO
Insulin
YES   NO
Kidney Disease
YES   NO
Glucophage
YES   NO
Other Medical Conditions
YES   NO
Asthma
YES   NO
 
Please describe other medical conditions:





Have you had any previous surgery, chemotherapy or radiation therapy?
Date

Procedure Done



Date

Procedure Done



Date

Procedure Done