Full Body Screen

FULL BODY SCREEN:

PREPARATION NPO 6 HOURS PRIOR TO EXAM. 1 BOTTLE BARIUM CONTARST ONE HOUR PRIOR TO EXAM.

RADIATION EXPOSURE LOWER THAN STANDARD CT

EXAM INCLUDES: CT SCAN CHEST, ABDOMEN, PELVIS & CALCIUM SCORE

THIS SCREENING INCLUDES THE STRUCTURES AND ORGANS WITHIN THE CHEST, ABDOMEN AND PELVIS. THIS EXAM IS USEFUL FOR THE EVALUATION AND DETECTION OF SILENT DISEASES AND CANCER, RISK OF OSTEOPOROSIS AND RISK OF CORONARY ARTERY DISEASE.

LUNG SCREENING ABDOMEN SCREEN PELVIS SCREEN

THE LUNG SCREEN DETECTS THE THE ABDOMEN SCREEN DETECTS THE THE PELVIS SCREEN DETECTS THE FOLLOWING: FOLLOWING: FOLLOWING:  SUSPECTED LUNG CANCER  LIVER TUMORS, HEPATOMEGALY,  BLADDER MASSES, TUMORS,  HILAR OR MEDIASTINAL CYST AND INFECTIONS DIVERTICULI, AND / OR ADENOPATHY (LYMPH  GALLSTONES COLON MASSES NODES)  PANCREATIC MASSES, TUMORS  PROSTATE ENLARGEMENT  PULMONARY INFECTION, AND CYSTS (MALE) PNEUMONIA, EMPHYSEMA,  KIDNEY TUMORS, CYSTS AND  OVARIAN AND UTERINE FLUID IN THE LUNG AND STONES, HYDRONEPHROSIS TUMORS, MASSES OR CYSTS NODULES (OBSTRUCTED KIDNEY) (FEMALE)  HEART CHAMBER  ADRENAL GLAND TUMOR AND  ABNORMALITY OF PELVIS ENLARGEMENT, HEART CYSTS BONE VALVE CALCIFICATION  DETECTION OF ABDOMINAL  ABNORMALITIES OF THE AORTIC ANEURISM, STENOSIS AND DISCLAIMER: AORTIC ARCH AND CALCIFICATION OF THE AORTA CALCIFICATIONS AND BRANCHES, WHICH CAN UNABLE TO DETECT THE FOLLOWING:  HIATAL HERNIA LEAD TO LEG PAIN AND  A NEGATIVE PROSTATE CT DIFFICULTY WALKING. DOES NOT EXCLUDE A DISCLAIMER:  LUMBAR SPINE TUMORS, MALIGNANCY. CORRELATION METASTASIS AND DEGENERATIVE WITH BLOOD TEST (PSA) AND UNABLE TO DETECT THE FOLLOWING: CHANGES. DIGITAL RECTAL EXAM BY A  THIS EXAM IS NOT DESIGNED PHYSICIAN ON ANNUAL BASIS FOR EVALUATING BREAST DISCLAIMER: IS ADVISED. MASSES. MAMMOGRAPHY OR  COLON LESIONS SUCH AS BREAST MRI ARE THE UNABLE TO DECTECT OR EVALUATE THE POLYPS CANNOT BE SCREENING EXAMS OF FOLLOWING: EVALUATED BY THIS CHOICE FOR THE BREAST.  HERNIATED DISCS AND SPINAL SCREENING. BARIUM ENEMA  LACK OF INTRAVENOUS CORD LESIONS CANNOT BE OR COLONOGRAPHY CONTRAST LIMITS TOTALLY EVALUATED BY THIS (VIRTUAL) SHOULD BE DONE. EVALUATION OF SMALL EXAM AND MRI WOULD BE  SMALL OVARIAN TUMORS OR MASSES ADJACENT TO THE INDICATED. CYSTS MAY NOT BE PULMONARY ARTERIES AND  STOMACH LESIONS SUCH AS DETECTED BY THIS VEINS. AREAS OF SCARRING ULCERS AND COLON LESIONS SCREENING EXAM. OR WITHIN THE TUBULAR SUCH AS POLYPS CANNOT BE TRANSVAGINAL AIRWAYS MAY BE DIFFICULT EVALUATED BY THIS EXAM, ULTRASOUND IS THE TO SEE ON OCCASION, UPPER GI, BARIUM ENEMA, OR IMAGING MODALITY OF MULTIPLE SMALL TUMORS COLONOGRAPHY STUDIES CHOICE. MAY BE INDISTINGUISHABLE (VIRTUAL) SHOULD BE DONE. FROM POST-INFLAMMATORY LUNG NODULES. HEART SCORE

THE PURPOSE OF THIS SCREENING EXAM IS USEFUL FOR EVALUATION AND DETECTION OF CALCIUM DEPOSITS IN THE CORONARY ARTERIES, WHICH HAVE BEEN SHOWN TO BE ASSOCIATED WITH CORONARY ARTERY DISEASE AND HEART ATTACK.

DISCLAIMER:

UNABLE TO DETECT OR EVALUATE THE FOLLOWING:  THE ABSENCE OF DETECTABLE CORONARY ARTERY CALCIFICATION BY MDCT IS HIGHLY UNLIKELY THE PRESENCE OF SEVERE LUMINAL OBSTRUCTIVE DISEASE.  ABSENCE OF DETECTABLE CORONARY ARTERY CALCIFICATIONS ON MDCT DOES NOT ABSOLUTELY EXCLUDE THE PRESENCE OF ATHEROSCLEROTIC PLAQUE, IT ONLY INDICATES THE PRESENCE IS LESS LIKELY.  THIS EXAM MAY MISS SINGLE VESSEL DISEASE LESS THAN 10% OF CASES.  THE OTHER RISK FACTOR SUCH AS HIGH CHOLESTEROL, HYPERTENSION, DIABETES OBESITY, GENERIC FACTORS AS WELL AS FAMILY MEDICAL HISTORY, SYMPTOMATOLOGY, AND OTHER DIAGNOSTIC TEST SHOULD BE TAKEN IN CONSIDERATION WHEN EVALUATING FOR CORONARY ARTERY DISEASE.  THIS EXAM DOES NOT REPLACE CONVENTIONAL CORONARY ANGIOGRAPHY FOR SYMPTOMATIC PATIENTS.  IF CAC IS PRESENT, CONSULTATION WITH A CARDIOLOGIST IS HIGHLY RECOMMENDED.  A POSITIVE SCORE ON THE EXAM IS AN INDICATION FOR LIKELY HOOD OF THE PRESENCE OF CORONARY ARTERY DISEASE.  THIS EXAM DOES NOT REPLACE CONVENTIONAL CORONARY ANGIOGRAPHY FOR SYMPTOMATIC PATIENTS.  IF CAC IS PRESENT, CONSULTATION WITH A CARDIOLOGIST IS HIGHLY RECOMMENDED.  A POSITIVE SCORE ON THE EXAM IS AN INDICATION FOR LIKELY HOOD OF THE PRESENCE OF CORONARY ARTERY DISEASE. A BENCHMARK AGAINST WHICH TO MEASURE THE PROGRESS OF CALCIFICATION AND EFFECTIVENESS OF PRESCRIBED TREATMENT.  HEART SCREENING DOES NOT DETECT LIPIDS SOFT PLAQUE.

IN ADDITION:

SINCE THIS IS A NON-INVASIVE SCREENING TEST FOR ASYMPTOMATIC PATIENTS ONLY, AND TO AVOID INCOVENIENCE TO YOU, FULL BODY SCREENINGS ARE PERFORMED WITHOUT THE USE OF INTRAVENOUS INJECTION OF CONTRAST MEDIUM (IODINE, ALSO KNOWN AS “X-RAY DYE”). THE LACK OF IV CONTRAST CAN MAKE IT DIFFICULT TO SEE SMALL LIVER LESIONS, AND DILATION OF THE BILIARY TREE. IT ALSO LIMITS THE EVALUATION OF RENAL CYSTS AND MILD HYDRONEPHROSIS.

IN ANYCASE, SHOULD WE FIND ANY SUSPICIOUS LESIONS, WE WILL ADVISE YOU AND RECOMMEND A FOLLOW UP WITH IV CONTRAST AGENTS. THESE ARE STANDARD FOR SYMPTOMATIC PATIENTS AND HAVE HIGHER RESOLUTION AND HIGHER DOSE CT. RARELY, A LIMITED NUMBER OF PATIENTS SHOW MILD TO SEVERE ALLERGIC REACTIONS TO THE INTRAVENOUS IODINE CONTRAST INJECTION. DUE TO THIS POTENTIAL RISK, SCREENING PROGRAMS ARE PERFORMED WITHOUT IV CONTRAST.

MEDICAL HISTORY QUESTIONAIRE

TODAY’S DATE______

PRINT YOUR NAME______

AGE:______D.O.B.__ /___/______HEIGHT:______WEIGHT:______

PART 1 CHECK THE BOX TO THE LEFT IF YOU HAVE HAD THE CONDITION/DISEASE PLEASE LIST CONDITIONS YOU HAVE HAD OR LISED BELOW. CURRENTLY HAVE THAT ARE NOT INCLUDED IN THE LIST TO THE LEFT: HAVE NOW UNDER ______OR TREATMENT? ______HAD CONDITION/DISEASE YES NO ______ALCOHOLISM ______ANEMIA ARTHRITIS MEDICATIONS LIST: ASTHMA ______BLOOD CLOTTING PROBLEMS ______CANCER OR TUMOR ______COLON OR BOWEL DISEASE ______DIABETES ______EMOTIONAL PROBLEMS ______EMPHYSEMA EPILEPSY OR SEIZURES GALLSTONES GALLBLADDER DISEASE PART 2 GLAUCOMA LIST ALL KNOWN ALLERGIES TO MEDICATIONS: GOUT HAY FEVER / ALLERGY PROBLEMS 1.______2.______HEART DISEASE (ANGINA, HEART ATTACK, ETC.) 3.______4.______HEART MURMUR AS AN ADULT HIGH BLOOD CHOLESTEROL HIGH BLOOD PRESSURE IMMUNE DEFICIENCY PART 3 KIDNEY OR BLADDER INFECTION HOSPITALIZATIONS AND OPERATIONS KIDNEY OR BLADDER STONES PLEASE INCLUDE ANY SPECIAL CONDITIONS OR KIDNEYS NOT WORKING WELL UNCOMMON INJURIES. LIVER DISEASE (HEPATITIS, CIRRHOSIS) PNEUMONIA YEARS(S) REASON FOR HOSPITALIZATION/SURGICAL PSORIASIS PROCEDURE RHEUMATIC FEVER STOMACH OR DUODENAL ULCER 1.______STROKE THRYROID DISEASE 2.______TUBERCULOSIS 3.______VENERAL DISEASE (SEXUALLY TRANSMITTED DISEASE; EXAMPLE: GENITAL HERPES, GENITAL 4.______WARTS, ETC.) LIST: 5.______PART 4 FAMILY MEDICAL HISTORY

CHECK THOSE RELATIVES WHO HAVE HAD ANY OF THE CONDITIONS BELOW: PARENTS AND SIBLINGS

FATHER MOTHER PARENTAL BROTHER SON CONDITION RELATED OR OR RELATIVE AGE AT DEATH CAUSE OF SISTER DAUGHTER & DEATH AGE IF LIVIING ALCOHOLISM BLOOD CLOTTING PROBLEMS FATHER CANCER/TYPE______MOTHER CANCER/TYPE______DIABETES BROTHER HEART ATTACK BROTHER HIGH BLOOD PRESSURE OSTEOPOROSIS BROTHER SICKLE CELL ANEMIA SISTER STROKE SISTER SUICIDE/MENTAL ILLNESS TUBERCULOSIS SISTER

LIST OTHER DISEASES WHICH YOUR MOTHER, FATHER, SISTER OR BROTHER HAVE OR HAVE HAD: ______

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PART 5 SOCIAL HABITS AND LIFESTYLE

OCCUPATION: ______

MARITAL STATUS: MARRIED SINGLE PARTNER WIDOWED DIVORCED OTHER: ______

*TOBACCO: (CHECK ANY THAT APPLY) *ALCOHOL USE: (CHECK ALL THAT APPLY)

HAVE NEVER SMOKED OR CHEWED TOBACCO WHAT IS (ARE) YOUR DRINK(S) OF QUIT DATE______PREFERENCE? ______SMOKE CIGARRETS PACKS PER DAY? ______SMOKE PIPE/CIGARS HOW MANY PER DAY? ______HOW MANY ALCOHOLIC DRINKS DO YOU CONSUME? CHEW TOBACCO HOW MUCH PER DAY? ______4+DRINKS DAILY 1-3 DRINKS DAILY 2-3 DRINKS WEEKLY 1-3 DRINKS MONTHLY *ABOUT HOW MANY YEARS HAVE YOU USED TOBACCO? ______NEVER DRINK ALCOHOL

ADDITIONAL DETAILS

PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT YOU FEEL WAS NOT ADDRESSED IN THIS QUESTIONNAIRE, AS WELL AS ANY DETAILS YOU FEEL ARE IMPORTANT FOR YOUR PHYSICIAN TO KNOW. PLEASE NOTE, IF YOU ARE HAVING ANY SYMPTOMS THAT MAY BE SERIOUS AND ARE NEW OR ARE WORSENING SIGNIFICANTLY ( SUCH AS CHEST PAIN, SHORTNESS OF BREATH, ABDOMINAL PAIN, SEVERE HEADACHES, ETC.) YOU SHOULD NOT WAIT. INSTEAD, YOU SHOULD CALL FOR AN APPOINTMENT NOW.

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