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Height: Weight: What can we do to make sure you receive very good care? Do you have someone with you today? Yes No If yes, Name: Cell phone number: Reason you are having this exam: Do you have a history of cancer? Yes No Did the treatment include: If yes, what type: Radiation therapy? Yes No Chemotherapy? Yes No If yes, what part of body: List any previous surgeries and date of surgery: Have you had any previous scans of the same area we are scannin.

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