Sample, Sammy G ST0001

Followup Form 1234567890


MM/DD/YYYY
MM/DD/YYYY

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.
First Name
Last Name

MM/DD/YYYY


COVID Status

MM/DD/YYYY
MM/DD/YYYY

COVID-19 Vaccination Record

MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY

MM/DD/YYYY
MM/DD/YYYY

Smoking History

Day
Month
Year

Health Survey

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.