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 this 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  
WHAT WAS YOUR CHIEF COMPLAINT WHEN YOU VISITED YOUR DOCTOR?





WHICH AREA IS AFFECTED?
UPPER RIGHT SIDE   UPPER LEFT SIDE
LOWER RIGHT SIDE   LOWER LEFT SIDE

ANY HISTORY OF CANCER?
YES   NO
IF YES, WHAT TYPE OF CANCER?




HOW LONG HAVE YOU HAD THIS PROBLEM?


ANY SURGERY OF THE ABDOMEN?
YES   NO
(A) IF YES, WHEN?:


(B) IF YES, WHAT WAS DONE?:


ANY OTHER MEDICAL CONDITIONS?
YES   NO
IF YES, PLEASE EXPLAIN:




DESCRIBE YOUR GENERAL HEALTH:




HAS YOUR GALLBLADDER BEEN REMOVED?
YES   NO