PATIENT’S PREGNANCY EVALUATION FORM

Dear Patient

In order for us to fully evaluate you we are required to take x-rays of some part(s) of your body. It has been predicted that an unborn child in its first trimester would be more sensitive to radiation than an adult. In order to insure that accidentally, knowingly or otherwise, no Fetus (unborn child) be exposed to radiation form x-ray machines, we ask you provide us with the following information. We thank you for the information and this information is strictly confidential and is solely used to the purpose it is intended.

Name:

Date:

Date of the onset of last menstrual period:

Is there any chance that you may be pregnant?

Yes No

To the best of my knowledge, I am not pregnant and by providing this application for Physician/Technologist has informed me of the effects of Radiation to the Unborn baby and me by signing below have consented to taking the x-rays of my body parts for further studies.