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?





ANY HISTORY OF CANCER ?
YES   NO
IF YES, WHERE?





IF YES, WHEN WAS IT FOUND?





ANY MASS OR SWELLING IN THE CHEST OR NECK?
YES   NO
IF YES, WHERE?





ANY HISTORY OF THYROID PROBLEMS?
YES   NO
IF YES, DESCRIBE?





DIFFICULTY SWALLOWING/SHORTNESS OF BREATH?
YES   NO
ANY CHEST OR NECK SURGERY?
YES   NO
IF YES, WHEN?





WHAT TYPE OF SURGERY WAS DONE?





ANY OTHER MEDICAL CONDITIONS ?
YES   NO
IF YES, DESCRIBE?





DESCRIBE YOUR GENERAL HEALTH:





DO YOU SMOKE?
YES   NO