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Colorado Heart & Body Imaging

Full Vascular Scan

Date:_____/_____/_____

Last Name: First: MI: Marital Status: .

Gender: M / F Birth Date: / / Age:_____ Height: ‘ “ Weight: lbs SS#: - - .

Mailing Address: Apt / Suite: .

City: State: Zip: Phone: ( ) -

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

E-Mail Address: @

Employer: Phone: ( ) -

Employer Address: Apt / Suite:

City: State: Zip: Fax: ( ) - _

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 consent.

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: __________________________

EBT CALCIUM SCAN QUESTIONAIRE (Heart | Lung | Abdomen | Pelvis)

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

Reason for the Whole Body (WB) scan:

Do you have a personal history of cancer? ÿ No ÿ Yes Type: When: / /

Have you had any previous abdominal surgery? ÿ No ÿ Yes

(If you answered Yes, what)

Have you ever been diagnosed with:

Tumors: ÿ No ÿ Yes What kind:

Stones: ÿ No ÿ Yes What kind:

Aneurysm: ÿ No ÿ Yes What kind:

Other Abnormality of abdomen or pelvis: ÿ No ÿ Yes

If yes, please describe:

Are you having abdominal or pelvic pain: ÿ No ÿ Yes

Recent unintentional weight loss or gain: ÿ No ÿ Yes

Current smoker: ÿ No ÿ Yes Number of packs: per day for years

Former smoker: ÿ No ÿ Yes Number of years since quitting:

SYMPTOMS

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

Last Name: _____________________________ First Name: __________________________

CURRENT SMOKER

Average packs per day: Total years smoked:

EX SMOKER

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

DO YOU KNOW YOUR CHOLESTEROL LEVEL? ÿ No ÿ Yes 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: ÿ No ÿ Yes For years Latest BP / Highest BP /

Diabetes: ÿ No ÿ Yes

Oral tablets: ÿ No ÿ Yes

Insulin: ÿ No ÿ Yes 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: ÿ No ÿ Yes 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: ÿ No ÿ Yes 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: ÿ No ÿ Yes

Last Name: _____________________________ First Name: __________________________

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:

WOMEN ONLY: Menopause: Y / N Hormone replacement: Y / N ÿ Hysterectomy ÿ Oophorectomy

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

CONSENT FOR ‘WHOLE BODY SCAN’ USING ELECTRON BEAM CT

A Body scan at Colorado Heart Imaging involves 3 separate procedures:

· The electron beam coronary artery scan (‘Heartscan’)

· An electron beam high resolution low dose CT scan of the chest (‘Lungscan’)

· A screening electron beam CT scan of the abdomen. A pulmonary function test (Spirometry) will usually be included.

1.) The coronary scan or Heartscan is recommended for middle-aged individuals for the very early detection of coronary disease.

2.) The chest scan is especially recommended for smokers (over the age of 45 who have been smoking at least 10 years) or for those heavily exposed to lung carcinogens (passive smokers, asbestos, etc). Most tiny nodules detected by this method will be benign and will often require follow-up scanning at least every 6 months for two years. Larger nodules need follow-up by a physician. Colorado Heart Imaging requires that the patient identify a physician who is willing to follow-up in case of positive findings.

3.) Screening Electron Beam CT of the abdomen is being offered a various centers nationwide as a response to consumer interest in diagnosing unexpected abdominal lesions including some cancers before symptoms. In our opinion, it is a practice that should not be encouraged for widespread use, but is available to qualified individuals who understand its limitations.

Colorado Heart Imaging requires that the patient identify a physician who is willing to follow-up in case of positive findings.

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Patient Signature Date

Last Name: _____________________________ First Name: __________________________

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, Spirometry, and or Cholestech.

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, spirometry, and or cholestech ,are intended as screening tools 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.

The body scan procedure is designed as a screen to look for abnormalities of the lungs, liver, kidneys, spleen, gallbladder, pancreas, aorta and abdominal lymph nodes. Cysts, stones, tumors, congenital abnormalities and vascular plaque are among the lesions detected. The procedure does not involve contrast dye injection; therefore many abnormalities will not be detected. Very small tumors, cysts and stones will not be detected. In addition, a patient consenting for the procedure understands that there may be a higher than usual likelihood for ‘false positives’ than in most diagnostic procedures in medicine. In other words, there may be the reporting of lesions of no significance or radiological findings, which are not, in fact, present. On occasion, a patient will be advised to follow up such an abdominal scan with a contrast CT scan or other procedures that may be recommended by a physician. It is also understood that radiology is not a perfect science and it is quite possible for a radiologist to miss a significant lesion or abnormality by this method. I also understand that a body scan is not adequate and not recommended to detect metastasis or to follow-up the progress of someone with a history of cancer. Such patients should only have a body scan if they are interested in a possible opportunity to find some problems, which are unrelated to their cancer diagnosis.

_________ PATIENT’S INITIALS

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.

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Signature Date

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

In order to allow patients to have a body scan or a lung scan, Colorado Heart Imaging requires that you:

ü Identify the name of a physician to whom we can send a copy of your medical report.

ü Give us permission to send a copy of the medical report for this procedure to the below named physician.

ü If you are a female patient you are not pregnant.

I hereby consent that Colorado Heart Imaging may send a copy of the medical report for this procedure 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: ( ) -

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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 p