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 NUCLEAR MEDICINE HISTORY FORM Medical Imaging 2011-2023


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Nuclear Medicine study before F Yes F No When Where RECENT PREVIOUS EXAMS PET. F Yes F MRI. F Yes F Ultrasound. F Yes F X-ray. F Yes F PREVIOUS EXAM FACILITY No SURGERY/ TREATMENT Prior Surgery F Yes F No If Yes please indicate surgery Type and Dates Surgery Type CANCER PATIENT ONLY Chemotherapy F Yes F No Date of last treatment Radiation Therapy F Yes F No Date of last treatment If yes what body part RECENT ACCIDENT/ INJURY INDICATE PAIN / INJURY Have you had a recent injury....
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