Ordering Information
Ordering information is required
ONLY
for Medicare/Medicaid patients.
information will be copied to CT report
Referring physician is required for all exams regardless of the information above. This should
be the "attending physician", which may be different that the individual ordering the exam. Only
enter one physician, and do not use suffixes.
COVID Status
Day
Month
Year
This survey asks for your views about your health. This information will help you keep track of how
you feel and how well you are able to do your usual activities. Answer every question by selecting
the answer as indicated. If you are unsure about how to answer a question, please give the best
answer you can. For each of the following questions, please choose the one option that best
describes your answer.