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CONFIRMING PREGNANCY STATUS PRIOR TO MEDICAL IMAGING

For any medical imaging exam that uses radiation, women between the ages of 11-55 will be asked about the possibility of pregnancy. A pregnancy consent form will be filled out to verify that there is no chance of pregnancy. If there is a chance of pregnancy for these exams, please take a pregnancy test before you arrive. You could be asked to defer your exam if there is a question about your status.

Below are the questions we will ask you for the consent form to verify your status:

  1. I am or I could be pregnant. (Yes, No, I don’t know)
  2. Start date of my last menstrual period: __________
  3. I am confident that I am not pregnant because:
    • I am using contraceptive methods (pill, IUD, condoms, etc.).
    • I have not been sexually active since my last menstrual cycle.
    • I have had a tubal ligation or hysterectomy.
    • My partner has had a vasectomy.
    • I am postmenopausal (no menstrual cycle for over a year).
    • I have not (or do not) engage in sexual activity that can lead to pregnancy.
    • Other: ____________