Patient Pregnancy Evaluation

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  • Patient Pregnancy Evaluation Form

  • The exam your doctor has ordered uses ionizing radiation which can have a severe health effect during pregnancy to an unborn baby. The possibility of severe health effects depends on the gestational age of the unborn baby at the time of exposure and the amount of radiation it is exposed to. Unborn babies are particularly sensitive to radiation during their early development, between weeks 2 and 15 of pregnancy. Such consequences can include stunted growth, deformities, abnormal brain function, or cancer that may develop sometime later in life. You should contact your doctor if you believe you may be pregnant to discuss possible side effects and the risks and benefits of the procedure. If you feel that you may be pregnant, please inform the radiologic technologist before your exam.

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  • By signing below, I have consented to taking x-rays of my body parts for further studies.

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