Theresa Wallace

 
 athena 
 23-09-23 7:17:13 pm EDT 
 Page: 47/86
 Theresa Wallace (id #11246122, dob: 92-06-11) 
 11 
 CAT SCAN QUESTIONNAIRE 
 Date: 23-02-09 Time: 
 PATIENT Theresa Wallace 
 Type 
 of 
 exam 
 heads 
 Referring Physician 
 Height 112 Weight 12 Date of Birth 48 Pregnant? Y N 
 LMP 
 Reason for exam 
 Seizere 
 Technologist Printed Name & Signature Authall 
 Date 18-08-28 Time 7:17 
 5 
 correct DOB, 08/25/75 
 dob: 92-06-11 (89 yrs) 
 CLY 
 BMC-353 Rev. 08/18
