For Testing Website - Medical Questionnaire
For any clarifications - please email us at bookings@securescanners.com
For patients without a referral
First Name
*
Last Name
*
Gender
*
MALE
FEMALE
Email
*
example@example.com
Mobile number
*
Home phone number
Date of birth
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height
*
Weight
*
Your address
*
Address
Street Address Line 2
City/County
Postcode
Postcode
Postal/Zip Code
*
Postal/Zip Code
Next of kin
*
Name
Relation
Phone Number
Your GP/Consultant
GP/Doctor name
Surgery/Clinic
Phone Number
Body Parts to be scanned
Please choose up to four body parts to be scanned, each of which will incur an additional cost. For assistance, please email us via bookings@securescanners.com.
Preferred Location
Sandwell
Walsall
Bromsgrove
Newcastle-under-Lyme
Cheltenham
Nottingham
Milton Keynes
Manchester
Sheffield
Ashton Under Lyne
Sleaford
Newton-Le-Willows
Oldham
Spalding
Newport
St Helens
Fitzwilliam
Pontypridd
Northwood, London
Oulton
Market Rasen
Pudsey
Barnet, London
Hendon
Frimley
Ealing, London
Golders Green, London
Preston
Weybridge
Louth
Kingston Upon Thames
Waterloo, London
Canary Wharf, London
Orpington
Skegness
Stratford, London
Thornton Heath, Croydon
Swansea
Southampton
Hornchurch, London
Fareham
Leigh on Sea
Eastbourne
Penrith
Cockermouth
North Shields
First Scan Required
*
Abdomen
Ankle-Left
Ankle-Right
Brain/Head
Breasts (Both)
Calf-Left
Calf-Right
Chest
Elbow-Left
Elbow-Right
Foot-Left
Foot-Right
Forearm-Left
Forearm-Right
Hands-Left
Hands-Right
Hip-Left
Hip-Right
IAMS (Both)
Knee-Left
Knee-Right
Lower Back (Lumbar Spine)
Middle Back (Thoracic Spine)
Neck (Cervical Spine)
Pelvis
Prostate
Shoulder-Left
Shoulder-Right
Small Bowel
Thigh-Left
Thigh-Right
Upper Arm-Left
Upper Arm-Right
Wrist-Left
Wrist-Right
Liver
Groin
Other
Type of Scan Requested for First Body Area
*
CT Scan
MRI Scan
MRI Upright scan
MRI Open scan
PET / CT
Ultrasound
Virtual Colonoscopy
X-Ray
Other
How long have you been complaining of symptoms in first body area?
*
What symptoms do you have in first body area?
*
Difficulty in moving
Dull ache
Feeling generally unwell
Headache
Limitation of movement
Limping
Numbness
Pain - sharp
Pins and Needles
Other
Symptoms Details
*
Please explain the symptoms for each body part requested for scan.
0/100
Total Cost ( for first scan )
Total Cost ( for second scan )
Total Cost ( for third scan )
Total Cost
Second Body Area to be scanned
None
Abdomen
Ankle-Left
Ankle-Right
Brain/Head
Breasts (Both)
Calf-Left
Calf-Right
Chest
Elbow-Left
Elbow-Right
Foot-Left
Foot-Right
Forearm-Left
Forearm-Right
Hands-Left
Hands-Right
Hip-Left
Hip-Right
IAMS (Both)
Knee-Left
Knee-Right
Lower Back (Lumbar Spine)
Middle Back (Thoracic Spine)
Neck (Cervical Spine)
Pelvis
Prostate
Shoulder-Left
Shoulder-Right
Small Bowel
Thigh-Left
Thigh-Right
Upper Arm-Left
Upper Arm-Right
Wrist-Left
Wrist-Right
Liver
Groin
Other
Type of Scan Requested for Second Body Area
*
CT Scan
MRI Scan
MRI Upright scan
MRI Open scan
PET / CT
Ultrasound
Virtual Colonoscopy
X-Ray
Other
How long have you been complaining of symptoms in second body area?
*
What symptoms do you have in second body area?
*
Difficulty in moving
Dull ache
Feeling generally unwell
Headache
Limitation of movement
Limping
Numbness
Pain - sharp
Pins and Needles
Other
Symptoms Details
*
Please explain the symptoms for each body part requested for scan.
0/100
Third Body Area to be scanned
None
Abdomen
Ankle-Left
Ankle-Right
Brain/Head
Breasts (Both)
Calf-Left
Calf-Right
Chest
Elbow-Left
Elbow-Right
Foot-Left
Foot-Right
Forearm-Left
Forearm-Right
Hands-Left
Hands-Right
Hip-Left
Hip-Right
IAMS (Both)
Knee-Left
Knee-Right
Lower Back (Lumbar Spine)
Middle Back (Thoracic Spine)
Neck (Cervical Spine)
Pelvis
Prostate
Shoulder-Left
Shoulder-Right
Small Bowel
Thigh-Left
Thigh-Right
Upper Arm-Left
Upper Arm-Right
Wrist-Left
Wrist-Right
Liver
Groin
Other
Type of Scan Requested for Third Body Area
*
CT Scan
MRI Scan
MRI Upright scan
MRI Open scan
PET / CT
Ultrasound
Virtual Colonoscopy
X-Ray
Other
How long have you been complaining of symptoms in third body area?
*
What symptoms do you have in third body area?
*
Difficulty in moving
Dull ache
Feeling generally unwell
Headache
Limitation of movement
Limping
Numbness
Pain - sharp
Pins and Needles
Other
Symptoms Details
*
Please explain the symptoms for each body part requested for scan.
0/100
Fourth Body Area to be scanned
None
Abdomen
Ankle-Left
Ankle-Right
Brain/Head
Breasts (Both)
Calf-Left
Calf-Right
Chest
Elbow-Left
Elbow-Right
Foot-Left
Foot-Right
Forearm-Left
Forearm-Right
Hands-Left
Hands-Right
Heart/Cardiac
Hip-Left
Hip-Right
IAMS (Both)
Knee-Left
Knee-Right
Lower Back (Lumbar Spine)
Middle Back (Thoracic Spine)
Neck (Cervical Spine)
Pelvis
Prostate
Shoulder-Left
Shoulder-Right
Small Bowel
Thigh-Left
Thigh-Right
Upper Arm-Left
Upper Arm-Right
Wrist-Left
Wrist-Right
Liver
Groin
Type of Scan Requested for Fourth Body Area
*
CT Scan
MRI Scan
MRI Upright scan
MRI Open scan
PET / CT
Ultrasound
Virtual Colonoscopy
X-Ray
Other
How long have you been complaining of symptoms in fourth body area?
*
What symptoms do you have in fourth body area?
*
Difficulty in moving
Dull ache
Feeling generally unwell
Headache
Limitation of movement
Limping
Numbness
Pain - sharp
Pins and Needles
Presence of a lump or bump
Stiffness
Swelling
Weakness
Other
Symptoms Details
*
Please explain the symptoms for each body part requested for scan.
0/100
Preferred Appointment Date
-
Day
-
Month
Year
Other Medical information
Have you seen a GP or Consultant regarding this problem?
*
No
Yes
Remarks by GP / Doctor / Consultant
*
Were you referred for any specific test? What was the result?
0/100
Are you in good general health?
*
No
Yes
Have you had any injuries or accidents?
*
No
Yes
Details of injury/accident
*
0/50
Have you had any operations in the past?
*
No
Yes
Not Sure
Details of operations
*
0/50
Other relevant details or family history
Please mention any other relevant clinical details or medical history
0/100
Please answer the questions below
*
Yes
No
Have you had any surgery in the last 8 weeks?
Do you have a cardiac pacemaker?
Do you have a cochlear implant or neurotransmitter?
Do you have aneurism clip anywhere?
Do you have a programmable ventriculoperitoneal shunt?
Do you have kidney/renal impairment?
Do you have any metal implants or prostheses?
Do you have any metal fragments in the eye?
Do you have any metallic tooth fillings?
Do you have any metallic braces?
Do you have any tattoos?
Are you pregnant or breast feeding?
Are you taking any medication or tablets?
Do you have any of the following:
*
Yes
No
Allergies
Asthma
Claustrophobia
Depression
Diabetes
Epilepsy
Heart Disease
High Blood Pressure
Do you have any comments or special requests?
0/50
Do you have any feedback about this form?
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