PET/CT Scan Request Form
Requested Study
Oncologic PET:
No
Yes
Diagnosis
Detection of recurrent disease
Radiation treatment planning
Staging/Restaging
Treatment monitoring/Treatment assessment
Cardiac PET:
No
Yes
Myocardial viability
Cardiac inflammation
Neuro PET:
No
Yes
Dimentia MMSE
Score:
Seizure
Tumor viability/Radiation necrosis
Pakinsonism
Suspected recurrence of previously treated tumor
Radiation treatment planning
PSMA PET:
No
Yes
Diagnosis
Detection of recurrent disease
Radiation treatment planning
Staging/Restaging
Treatment monitoring/Treatment assessment
Special need (if any):
Patient Information
Patient Name: *
HN: *
Telephone: *
Email:
SEX: *
Please select sex
Male
Female
Being Pregnancy:
No
Yes
Allergies:
Iodine:
Other:
Claustrophobia: *
Please select
No
Yes
DM: *
Please select
No
Yes
Oral Medication
Insulin Injection
Inflammation/Infection in the past 3 months:: *
Please select
No
Yes
Hospital or clinic’s name: *
Inpatient:
Outpatient:
Indication of study and related history
Diagnosis: *
Previous imaging investigation:
No
Yes
pls. indicate the name of the investigation:
date done:
Staging:
Unknown
Know
T:
N:
M:
Previous treatment
- Surgery/intervention:
No
Yes
Date: *
Surgical site / Operation: *
- Chemotherapy:
No
Yes
The last cycle: *
The next cycle: *
- Radiation:
No
Yes
Location: *
Please indicate the last radiation duration: *
Previous Investigation
- Ultrasonography: (Within 3 months)
No
Yes
Date:
- MRI: (Within 3 months)
No
Yes
Date:
- PET/CT:
No
Yes
Date:
No. of the scan in the last 12 months:
- CT: (Within 3 months)
No
Yes
Date:
- Other Nuclear Medicine scan: (Within 3 months)
No
Yes
Date:
Please indicate:
- Tumor marker: (Within 3 months)
No
Yes
pls. Indicate:
Date:
Referring physician
Physician name: *
license no.: *
Telephone: *
Email:
