X-Ray Questionnaire

X-ray Questionnaire

Please complete this questionnaire before booking your private chest X-ray. This service is for screening or administrative purposes only.

X-rays use ionising radiation. This questionnaire checks suitability before payment. This service is not suitable if you currently have chest symptoms.

Patient details

First name * Last name * Date of birth * Gender * Email * Phone number *

Chest X-ray request details

Reason for chest X-ray * Are you pregnant or could you be pregnant? * Have you had a previous chest X-ray or chest scan? * Do you currently smoke, or have you smoked in the past? *

Chest symptom exclusion questions

To continue, you must confirm that you do not currently have symptoms that need medical assessment before booking a screening chest X-ray.

Do you currently have a cough? * Do you currently have shortness of breath or wheeze? * Do you currently have chest pain? * Have you coughed up blood? * Do you have fever, night sweats, or unexplained weight loss? * Do you feel acutely unwell? *

Chest X-ray declaration

I confirm that I do not currently have cough, shortness of breath, wheeze, chest pain, coughing blood, fever, night sweats, unexplained weight loss, or feel acutely unwell.

I confirm that this chest X-ray is for screening or administrative purposes, and not for investigating current chest symptoms.

Declaration

I confirm that the information I have provided is accurate.

I understand that my x-ray request may still be reviewed before the appointment is confirmed.

I consent to being contacted about this x-ray request.

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