HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.GP referral questionnaireCT scan questions follow. Advanced technology optimizes patient outcomes and healthcare efficiency.These questions help the GP assess the patient's condition, determine the necessity of the CT scan, and ensure the patient's safety and well-being throughout the imaging process.Name(Required) First Last Email Address(Required) Symptoms:What symptoms are you experiencing that are prompting the need for a CT scan?(Required)When did these symptoms first appear?(Required)Are there any specific triggers or patterns associated with your symptoms?(Required)Have these symptoms worsened over time or stayed the same?(Required)Family History:Do you have any family history of relevant medical conditions, such as cancer, heart disease, or neurological disorders?(Required)Recent Events:Have you undergone any recent medical procedures or treatments?(Required)Have you experienced any recent injuries or traumas that might be related to your symptoms?(Required)Medical History:Do you have any pre-existing medical conditions?(Required)Are you currently taking any medications? If so, please list them.(Required)Do you have any known allergies, particularly to contrast dye used in imaging?(Required)Have you had any previous surgeries or medical procedures?(Required)Pregnancy and Radiation Exposure:Are you pregnant or could you possibly be pregnant?(Required)Have you had any recent exposure to radiation, such as through medical imaging or occupational exposure?(Required)Preparation:How would you describe your overall health and lifestyle?(Required)Are you aware of any specific preparations you need to undertake before the CT scan, such as fasting or discontinuing certain medications?(Required)Do you smoke or consume alcohol, and if so, how frequently?(Required)Do you have any concerns or questions about the CT scan procedure itself?(Required) Please rate us 0 / 5 Your page rank: