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

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?





DO YOU HAVE A HISTORY OF HEADACHES?
YES   NO
IF YES, ON WHAT SIDE?
LEFT   RIGHT  BOTH
DO YOU HAVE A HEARING LOSS?
YES   NO
IF YES, ON WHAT SIDE?
LEFT   RIGHT  BOTH
DO YOU EXPERIENCE DIZZINESS OR NAUSEA?
YES   NO
DO YOU HAVE ANY WEAKNESS OR NUMBNESS IN YOUR ARMS OR LEGS?
YES   NO
IF YES, WHEN DID IT BEGIN ?





IF YES, ON WHAT SIDE?
LEFT   RIGHT  BOTH
HAVE YOU EXPERIENCED ANY VISION LOSS?
YES   NO
IF YES, ON WHAT SIDE?
LEFT   RIGHT  BOTH
ANY LOSS OF CONCIOUSNESS RECENTLY ?
YES   NO
ANY SURGERY IN THE HEAD REGION ?
YES   NO
IF YES, WHEN?





IF YES, WHAT WAS DONE?





ANY HISTORY OF CANCER?
YES   NO
DESCRIBE ANY OTHER MEDICAL CONDITIONS:






DESCRIBE YOUR GENERAL HEALTH:






DESCRIBE ANY FOOD OR MEDICINE ALLERGIES: