PLEASE FILL OUT EACH PAGE COMPLETELY TO YOUR BEST KNOWLEDGE AND SIGN EACH PAGE

Heart & Lung Scan

Colorado Heart & Body Imaging Date: / /

Last Name: First: MI: Marital Status:

Sex: M / F Birth Date: / / Age: Height: ‘ ‘’ Weight: lbs SS#: / /

Mailing Address: Apt / Suite:

City: State: Zip: Phone: ( ) - Work: ( ) -

Physical Address (If different): City: State: Zip:

E-Mail Address: @ .

Employer: Phone: ( ) -

Employer Address: Apt / STE:

City: State: Zip:

Emergency Contact Name: Phone: ( ) -

Do you have a written Doctor’s order?________________________________

Name of referring doctor if applicable__________________________________________

By signing this form, I am granting consent to Colorado Heart Imaging, LLC. to use and disclose my protected health information (PHI) for the purposes of treatment, payment and health care operations; I also understand I will be responsible for all non-covered services because of a lack of authorization or any other reason for denial. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this PHI. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and by signing this document you fully understand the contents of our Notice of Privacy Practices.

Our Notice of Privacy Practices is subject to change at any time without notice. If we change our notice, you may obtain a copy of the revised notice by stopping by one of our facilities. You have a right to request us to restrict how we use and disclose your PHI for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your PHI information in reliance on your acknowledgement of receipt of Notice of Privacy Practices. I have been presented with a copy of this provider’s Notice of Privacy Practices detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the notice, and subject to the following restriction(s) concerning my personal medical information, I agree to the disclosures named in the notice:

Notice of Privacy Practices

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Signature Date

Last Name: _____________________________ First Name: __________________________

EARLY LUNG CANCER DETECTION

Please answer the following questions to the best of your knowledge:

Reason for lung scan:

SYMPTOMS

Cough	ÿ Never	ÿ Occasionally	ÿ Frequent	ÿ Continuous
Coughing up blood (Hemoptysis)	ÿ Never	ÿ Occasionally	ÿ Frequent	ÿ Continuous
Chest pain or discomfort	ÿ Never	ÿ Occasionally	ÿ Frequent	ÿ Continuous
Shortness of Breth (Dyspnea)	ÿ Never	ÿ Occasionally	ÿ Frequent	ÿ Continuous

RISK FACTORS

Asbestos exposure	ÿ No	ÿ Yes
Radon exposure	ÿ No	ÿ Yes
Beryllium exposure	ÿ No	ÿ Yes
Family history of lung cancer*	ÿ No	ÿ Yes
Exposure to second hand smoke**	ÿ No	ÿ Yes
Recent unintentional weight loss	ÿ No	ÿ Yes

*Family history includes parents and or siblings

**Exposure of non-smokers to environmental tobacco smoke (smoke released from a burning cigarette and smoke exhaled from a smoker)

PERTINENT PAST PULMONARY MEDICAL HISTORY

Asthma	ÿ No	ÿ Yes
Pulmonary fibrosis	ÿ No	ÿ Yes
Prior lung cancer (less than 5 years ago)	ÿ No	ÿ Yes
Prior TB history	ÿ No	ÿ Yes
Granulomatous disease	ÿ No	ÿ Yes
Other: ____________________________

CURRENT SMOKER Y / N

Average packs per day: ________ Total years smoked: _________

EX SMOKER Y / N

Average packs per day: ________ Total years smoked: _________

Approximate number of years since quitting:

PREVIOUS CHEST X-RAY DATE ______/______/______

Results ÿ Normal ÿ Unavailable ÿ Abnormal suspicious for cancer ÿ abnormal not suspicious for cancer

WOMEN ONLY

Menopause: Y / N Hormone replacement: Y / N

If you are pregnant or think you might be pregnant; you should not have the EBCT test.

Last Name: _____________________________ First Name: __________________________

EBT CALCIUM SCAN QUESTIONAIRE

Please answer the following questions to the best of your knowledge:

DO YOU KNOW YOUR CHOLESTEROL LEVEL: Y / N Date Checked: / /

HDL (Good) Cholesterol Amount (If known)

LDL (Bad) Cholesterol Amount (If known)

Triglycerides Amount (If known)

Total Cholesterol Amount (If known)

High blood pressure: Y / N For years Latest BP / Highest BP /

Diabetes: Y / N Oral tablets: Y / N Insulin: Y / N How long on medication:

FAMILY MEDICAL HISTORY

Father	ÿ Stroke	ÿ Hypertension	ÿ Diabetes	ÿ Heart Disease before 55	ÿ Heart Disease after 55
Brother	ÿ Stroke	ÿ Hypertension	ÿ Diabetes	ÿ Heart Disease before 55	ÿ Heart Disease after 55
Mother	ÿ Stroke	ÿ Hypertension	ÿ Diabetes	ÿ Heart Disease before 55	ÿ Heart Disease after 55
Sister	ÿ Stroke	ÿ Hypertension	ÿ Diabetes	ÿ Heart Disease before 55	ÿ Heart Disease after 55

PERSONAL HISTORY

EXERCISE REGULARLY: Y / N Number of days per week

ÿ < 30 MIN ÿ 30 -45 MIN ÿ 45 – 60 MIN ÿ > 60 MIN

CURRENT STRESS LEVELS: ÿ Very high ÿ High ÿ Above average ÿ Average ÿ Low ÿ N/A

CARDIAC SYMPTOMS:

ÿ None

ÿ Chest pain (when / describe):

ÿ Shortness of breath (when / describe):

ÿ Chest tightness or pressure (when / describe):

ÿ Frequent palpitations (when / describe):

ÿ Syncope / fainting or near fainting (when / describe):

Do you have any known cardiovascular disease: Y / N What type:

PAST CARDIAC MEDICAL PROCEDURES

ÿ None

ÿ Bypass surgery (when):

ÿ Angioplasty (when):

ÿ Personal heart attack (when):

ÿ Stent placement (when / which vessels):

Do you have anxiety or panic attacks causing chest pain: Y / N

PAST DIAGNOSTIC TESTS

ÿ Previous EBCT Scan (when):

ÿ Angiogram (when):

ÿ Thallium treadmill (Nuclear study) (when / results):

ÿ Exercise treadmill (when / results):

ÿ Stress echocardiogram (Ultrasound) (when / results):

MEDICATIONS CURRENTLY TAKING ÿ Daily Aspirin ÿ Antioxidants (vitamin C and or vitamin E)

PLEASE LIST ANY OTHERS: _ _____________________________________________________________________________

____________________________________________________________________________________________________________

Last Name: _____________________________ First Name: __________________________

WOMEN ONLY

Menopause: Y / N Hormone replacement: Y / N

If you are pregnant or think you might be pregnant, you should not have the EBCT test.

PREVENTION SCREENING DISCLOSURE AND CONSENT

I voluntarily consent and authorize Colorado Heart Imaging physicians, technologists, and medical assistants to administer the testing required to perform EBCT Ultrafast Cardiac screening test.

IF YOU ARE CURRENTLY EXPERIENCING CHEST SYMPTOMS: PAIN – SHORTNESS OF BREATH – ETC.

YOU MUST PROVIDE US WITH A PHYSICIAN’S NAME TODAY

I realize that there is a small amount of radiation exposure associated with the EBCT procedures. I further understand that although this screening can help identify certain early disease states, it should not be considered a substitute or in place of a thorough examination or testing recommended by a physician. Like all diagnostic tests, a normal scan does not guarantee that I will not have a heart attack or need treatment for coronary disease.

I understand that the EBCT Ultrafast examinations are intended as a screening tool and the possibility exists that abnormalities may be found. If such abnormalities are found, I understand that such testing and or diagnostic procedures may be needed to further evaluate the findings. I do understand that such tests and or procedures may entail additional costs for which I am responsible. I understand that Colorado Heart Imaging is not responsible for my follow-up medical care. My results will be made available to the physician of my choice.

I have been given an opportunity to ask questions about this procedure and the risks and hazards involved and I believe that I have sufficient information to give this informed consent. I certify that I have read this form and I understand its contents.

/ /

Signature Date

I understand that a zero or minimal score does not imply a zero risk of a heart attack or coronary event.

The report for any of the above procedures contains medical terminology that is likely to require interpretation by a physician.

By signing, I hereby consent that Colorado Heart Imaging may send a copy of the medical report(s) for this procedure(s) to my physician.

PLEASE PRINT CLEARLY

Physician Name

Physician Address

( ) -

Physician City State Zip Phone

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Patient Signature Date

Last Name: _____________________________ First Name: __________________________

In an effort to protect your privacy, we have developed a policy on leaving medical care messages.

We will NOT leave messages with anyone except the patient or legal guardian.

We will NOT leave any information on an answering machine / voice mail.

UNLESS

We have your written permission to do so. Please read below and consider carefully whom you want to have access to your medical information.

I, give Colorado Heart Imaging LLC, PC my permission to leave phone messages regarding my medical care and information as listed below. I fully understand that this authorization will remain valid until revoked in writing.

My home / mobile answering machine / voice mail: Phone: ( ) -

My office / work voice mail: Phone: ( ) -

My spouse: Name Phone: ( ) -

Other: Phone: ( ) -

/ /

Patient Signature Date

FINANCIAL POLICY

We are committed to providing you with the best possible care, and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship.

We must emphasize that as health care providers our relationship is with you, not your insurance company.

Ø Your insurance is a contract between you, your employer, and the insurance company.

Ø Patients covered under a PPO / HMO plan are responsible for complying with PPO / HMO rules, regarding written and phone referrals from primary care physicians, if that is a requirement of your plan.

Ø Failure to comply with the referral requirements of your plan will make it necessary for us to bill you directly for charges incurred during a non-referral visit.

Ø We will process claims with PPO / HMO plans with which we have a contract agreement, according to that agreement.

Ø Required co-payments if applicable should be made on the day services are provided.

Payment for service is due at the time service is rendered. You are responsible for timely payment of your account, and for any balance remaining after insurance payment has been received. There will be a $25.00 charge for all checks returned for insufficient funds.

I have read the above information; I understand and agree that I am responsible for the payment of professional services rendered.

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Patient Signature Date

WELCOME TO COLORADO HEART & BODY IMAGING

Date: Name:

Please take a moment to let us know how you heard about us!

Colorado Heart and Body Imaging invests in consumer education and awareness programs, through many different marketing avenues.

We would appreciate your time to answer the questions below.

This will enable us to focus our attention on the areas that best suits our community.

Which procedure(s) are you having done today:

(please check all that apply)

ÿ EBCT (Heartscan)

ÿ Lung

ÿ Whole Body

ÿ Virtual Colonoscopy

ÿ QCT (Bone Density)

What single event prompted you to schedule for this procedure:

Of the many different avenues of education and awareness programs that we publicize, which ONE was the most effective for you personally:

ÿ Physician Referral Physician Name:

ÿ Workplace: ____________________________________________________________

ÿ Seminars / Lectures Name / Date attended:

ÿ Internet: Site or Advertisement Name: _______________________________________

ÿ TV: Advertisement/News Story Title/Station: _________________________________

ÿ Radio: Advertisement/Station: _____________________________________________

ÿ Print (newspaper / magazine): _____________________________________________

ÿ Family / Friend: ________________________________________________________

ÿ Other:

Your input is very important and valuable to Colorado Heart Imaging. Thank you for taking the time to help us serve our community.