M EDICAL  PET  G ROUP (E0601)
PATIENT FORM  
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GENERAL PATIENT DATA
first name :
last name :
address :
city :
zip :
phone :
fax :
birth date (day/month/year) :
If the referral form is not provided by a physician
or the patient, please add the following data:
first name :
last name :
ref. :
REFERRING PHYSICIAN
first name :
last name :
address :
city :
zip :
speciality :
phone :
fax :
email :
REASON FOR A PET EXAMINATION
confirm diagnosis/second opinion
primary diagnostics/staging
therapy follow up/restaging
Sonstiges 		DIABETES KNOWN?
yes
no

MEDICAL DATA

aim of the exam. / preliminary diagnosis :


performed exam.
conv. x-ray, date :
ultrasound, date :   
surgery, date :       
MRI, date :           
computed tomography, date :
szintigraphy, date :
further exam. :

patient history/performed therapies
(e.g. chemotherapy, surgery, radiation therapy....):


current treatment
(drugs, dose, application):

FURTHER DATA

allergy:


current treatment/diag. in a hospital?
yes
no

immediate report needed?
yes
no

suggested exam. date :
    ATT.: THE PATIENT SHOULD NOT HAVE ANY FOOD WITHIN FOUR HOURS PRIOR TO PET WITH FDG !!!
current date :