Download to read offline
Uploaded byWendy Cahill
Pregnant patient form
This document is a form from Dr. R. Mark Pappas's chiropractic center addressing a patient's pregnancy and menstrual history before receiving x-rays. It notes that x-rays can injure fetuses and that the 10 days following a period are generally safe. It asks the patient to confirm their pregnancy and contraceptive status and provides a signature line to consent to x-rays if not at current risk.
Pregnant patient form
- 1. Pappas Chiropractic Center Dr.R. Mark Pappas 299 Main Street West Haven, Ct. 06516 Patient Name _________________________ Today's date is: ________________ I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus. I have been advised that the 10 days following onset of a menstrual period are generally considered to be safe for X-rays exams. With those factors in mind, I am advising my doctor that: Yes No Don't Know I am pregnant ........... ............ ............. I could be pregnant ........... ....... ..... ............. I am late with my menstrual period ........... ............ ............. I am taking oral contraceptives ........... ............ ............. I have an IUD ........... ............ ............. I have had a tubal ligation ........... ............ ........... .. I have had a hysterectomy ........... ............ ............. I have irregular menstrual periods ........... ............ ........... .. My last menstrual period began on:________________ With full understanding of the above, and believing that I am not currently at risk, I wish to have an X-ray examination performed now. __________________________ Signature