Pre-Register

Date

Patient Name

Date of Birth

Referring Physician

Reason for Exam

Obstetric Ultra Sound
MRI
Other - Explain:

Total number of pregnancies including this pregnancy

Delivery Due Date

# of pregnancies delivered

# of Miscarriages

# of C-sections

# of Ectopic pregnancies with Sides and Treatment

Indicate if any of the following conditions apply to your medical history

Diabetic

No	Yes - Explain:

Do you take insulin?

No

Yes

Do you have only gestational diabetes?

No	Yes - Explain:

Cigarette smoker? If Yes, how many cigarettes/packs per day?

No	Yes - Explain:

High blood pressure

No

Yes

Vaginal bleeding this pregnancy (when?)

No	Yes - Explain:

Uterine pain or cramping

No

Yes

Amniocentesis

No

Yes

Reduction in fetal movement

No

Yes

No fetal heart tones heard at Doctor's office

No	Yes - Explain:

Abnormal blood screening

No	Yes - Explain:

Personal/family history of congenital defects

No	Yes - Explain:

Significant medication or drug use during pregnancy

No	Yes - Explain:

Prior ultrasound of this pregnancy not at Diagnostic Imaging of Salem (when/where?)

No	Yes - Explain:

Other pertinent OB/Gyn history

Fetal Gender Survey
Indicate if you want to know the gender of your baby if seen during the ultrasound exam

YES

NO

Determination of fetal gender is considered a non-diagnostic component of the ultrasound examination. Ultrasound is not 100% accurate in determining gender. patient factors, fetal size and position, and reduced amniotic fluid are some factors that limit visualization and accuracy of gender determination.

Do you have any of the following?

Pacemaker

No

Yes

Implanted Cardiac defibrillator

No

Yes

Brain aneurysm clip(s) or other vascular clip(s)

No

Yes

Cochlear (inner ear) implant(s)

No

Yes

Ocular (eye) implant(s)

No

Yes

Cardiac stents (if Yes, date of placement)

No	Yes - Explain:

Coils, filters, or shunts

No

Yes

Transdermal patches (nitro or other)

No

Yes

Tattoos

No

Yes

Any history of cancer

No	Yes - Explain:

Any history of diabetes

No	Yes - Explain:

Any history of kidney disease

No	Yes - Explain:

Are you on dialysis

No

Yes

Exposure of metal to eyes

No

Yes

Always worn eye protection

No

Yes

Sometimes

Metal fragment(s) removed from eyes by a physician

No

Yes

Women Only
Are you pregnant?

No

Yes

Not sure

Wearing an IUD or diaphragm

No

Yes

Breastfeeding

No

Yes

Claustrophobic

No

Yes

Not sure

List surgeries that you've had and years you had them

Overall Final Check
Any other metal, implants of any kind, or electronic devices within or around the body (orthopedic metal such as pins, screws, plates, joint replacements, breast tissue expanders, staples, drug infusion pumps, shrapnel, or other metal from a firearm injury, electronic stimulators, body piercings...)? If so, please list and specify

No	Yes - Explain:

Overall Final Check
Any other metal, implants of any kind, or electronic devices within or around the body (orthopedic metal such as pins, screws, plates, joint replacements, breast tissue expanders, staples, drug infusion pumps, shrapnel, or other metal from a firearm injury, electronic stimulators, body piercings...)? If so, please list and specify

No	Yes - Explain:

I hereby verify that the questions answered are accurate to my knowledge: (Please type in full, legal name)

Diagnostic Imaging of Salem

Contact Info

Pre-Register