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Dexa
CT scan
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X-Ray
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Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
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CT Patient Questionaire for IV contrast
"
*
" indicates required fields
Name
*
Date Of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Do you have a history of cancer?
*
Yes
No
If yes, what type, where? Year? (Mark Any That Apply):
*
Breast
Prostate
Lung
Colon
Other
If other, what type?
*
Any prior imaging/scans on the body part we are scanning today?
*
Yes
No
If yes, what type, where? Year? (Mark Any That Apply):
*
CT
MRI
Ultrasound
X-ray
Other
If other, what type?
*
Prior surgery?
*
Yes
No
If yes, what type, where? Year? (Mark Any That Apply):
*
Gallbladder
Appendix
Other
If other, what type?
*
Reason you are here today? (Please list the problem, the area(s) experiencing the problem and when it started)
*
Do you have a history of asthma?
*
Yes
No
Have you had an asthma attack in the last 24 hours?
*
Yes
No
Use an asthma inhaler/oral asthma medication every day?
*
Yes
No
Ever been hospitalized for asthma?
*
Yes
No
Ever had a severe allergic reaction requiring hospitalization, or epinephrine?
*
Yes
No
Have you had any contrast study in the last 5 days?
*
Yes
No
Ever had any type of reaction to x-ray/CT contrast (x-ray/CT dye)?
*
Yes
No
If yes, what reaction did you have?
*
Ever taken/been instructed to take a steroid medication in preparation for any x-ray/CT with contrast study (x-ray/CT dye?)?
*
Yes
No
If yes, have you taken a steroid medication in preparation for today’s exam?
*
Yes
No
History of (Check any that apply):
*
Kidney/Renal Disease
Dialysis
Kidney Transplant
Single Kidney
Renal Cancer
Renal Surgery
Taking Medication For High Blood Pressure
Diabetes
Taking Metformin
Heart/Cardiac History
Angina
Congestive Heart Failure
Severe Aortic Stenosis
Pulmonary Hypertension
Severe Cardiomyopathy
Myasthenia Gravis
Multiple Myeloma
Breastfeeding
None
-It is generally regarded as safe to continue breastfeeding after receiving contrast. It is your choice however and, if you are still concerned, you may stop for 24 hours following the contrast injection. -It is recommended to discontinue Metformin 2 days post procedure, verify with your physician if this applies to you. -Your physician has requested that we perform a computerized tomography (CT) scan. In certain cases the radiologist may determine that the usefulness of your CT scan may be improved by administering intravenous iodinated contrast. Most patients experience no unusual effects from this injection other than some warmth or minimal flushing which is very common. As with the injection of any medicine or drug however, a few risks are involved, most of which are mild and momentary: slight nausea, or medicinal or metallic taste in the mouth. There can also be minor reaction such as itching, sneezing or a few hives. Uncommonly there can be more serious reactions including kidney failure, thrombophlebitis, skin necrosis and in extremely rare case, death. Our facilities are equipped to immediately treat these unusual reactions. In ordering this study, your doctor has determined that the diagnostic information which is provided outweighs the risk (usually minimal) of the procedure. The radiology personnel can answer any specific questions you may have. I understand the explanation given to me and give my consent to the CT scan with contrast.
Signature of Patient/Legal Guardian:
*
Date:
*
MM slash DD slash YYYY