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Patient Screening Form
Patient Information
Name:_____________________________________________________________ Body part to be examined:______________________________________________________ Reason for exam and/or symptoms:_______________________________________________________________________ How long have you had symptoms?_______________________________________________________________________ Medical Information
1. Have you had a reaction to a contrast medium or dye used for imaging? Yes If yes, have you been premedicated? Yes 2. Have you had a prior imaging study (MRI, CT, Ultrasound, X-ray, etc.)? 3. Have you had a prior cystoscopy or endoscopy? Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ Type of Surgery:_____________________________________________ Date:______________________ 5. Do you have:  diabetes  vasculitis  high blood pressure  renal disease/disorder  multiple myeloma  pheochromocytoma  heart disease/disorder  lupus  respiratory disease  sickle cell anemia/trait  congestive heart failure (CHF)  systemic lupus erythematosus (SLE)  liver failure  allergies ______________________ ____________________ _________________________ _____________________ ____________________ _________________________ 6. Do you take Actoplus Met, Avandamet, Diaben, Diabex, Diaformin, Fortamet, Glucophage, Glucovance, Gluformin, Glumetza, Janumet, Kombiglyze, Metaglip, Metformin, Obimet, Prandimet, or Riomet? Yes 7. List current or recently taken medication and doses:_______________________________________ Unknown ________________________________________________________________________________ 8. Are you a smoker or a former smoker? Yes 9. Do you have a personal history of cancer? If yes, describe type:_______________________________________________________________ Describe current or past treatments: (i.e. radiation or chemotherapy) _________________________ Date of treatment: _________________________________________________________________ 10. Please list any additional information you feel pertinent to today's exam:_______________________ ________________________________________________________________________________ **Please complete and sign back of form**
Form # CL072A Revised: 09-01-13
For Female Patients Only
1. Date of last menstrual period: __________________________ 2. Are you pregnant or experiencing a late menstrual period? If yes, was it a complete hysterectomy? (removal of ovaries and uterus) Date of surgery:____________________________________ 4. Are you taking oral contraceptives or receiving hormonal treatment? Staff Use Only

Staff Notes:_____________________________________________________________________________________________
______________________________________________________________________ Staff Signature:_____________________________________________ Date:_____________________________________
Medical Records Release
_____________________________________________________________________________________________ Please sign the medical release below.
This allows our facility to obtain your previous exams or prior medical history as it pertains to today’s exam.
_______________________________________________________ _______________________________________________________ _______________________________________________________ Patient Name:_________________________________________________________________________________________ Social Security #:_____________________________________ Date of Birth:________________________________ Type of records requested:_______________________________________________________________________________ I hereby authorize and request you to release the complete medical records mentioned above, including copies of the reports in your possession to Diagnostic Imaging Centers, PA. ___________________________________________________ ___________________________________________ Patient or Authorized Person Patient Signature
Patient Signature____________________________________ Date__________________________________________
Technologist________________________________________ Technologist___________________________________

5400 North Oak • Kansas City, MO 64118 • 816-455-5959 4911 S. Arrowhead Drive, Suite 100 • Independence, MO 64055 • 816-795-7040  301 NE Mulberry, Suite 100 • Lee’s Summit, MO 64086 • 816-554-0040 13795 S. Mur-Len Rd, Suite 100 • Olathe, KS 66062 • 913-397-7272 5500-5520 College Blvd. • Overland Park, KS 66211 • 913-491-9299 4801 Main, Suite 200 • Kansas City, MO 64112 • 816-561-5151 Form #CL072B Revised: 09-01-13



MEDICATIONS AND TOURETTE’S DISORDER: COMBINED PHARMACOTHERAPY AND DRUG INTERACTIONS Barbara Coffey, M.D., Cheston Berlin, M.D., Alan Naarden, M.D. Introduction Tourette Syndrome (TS) or Tourette’s Disorder (DSM IV) is a complex neuropsychiatricdisorder characterized by a changing pattern of motor and vocal tics that begin in childhood. Many individuals with Tourette Syndrome have a


Evolution and Human Behavior 27 (2006) 345 – 356Age and social position moderate the effectJacky Boivina,4, Kathy Sandersb, Lone SchmidtcaSchool of Psychology, Cardiff University, Cardiff, CF10 3AT Wales, UKbSchool of Anatomy and Human Biology, University of Western Australia, Crawley WA 6009, AustraliacInstitute of Public Health, Department of Social Medicine, University of Copenhagen,

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