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PATIENT INFO MEDICAL
OUTPATIENT CT
QUESTIONNAIRE
NEUROSCIENCE IMAGING CENTER
Have you ever been diagnosed with any of the following? * If you are a Diabetic, please indicate if you take any of the following: ( GLUCOPHAGE / GLUCOVANCE / METAFORMIN /
Are you allergic to any medicines that you are aware of? ADVANDAMET / METAGLIP)
Yes_________ No_________ What__________________________________________________________________ Yes_________ No_________ What__________________________________________________________________ AUTHORIZATION FOR CONTRAST INJECTION FOR ANY STUDY REQUIRING CONTRAST MATERIAL
I HAVE HAD contrast material in the past and WAS NOT allergic to it at that time.
I HAVE HAD contrast material in the past and WAS allergic to it.
I HAVE NEVER HAD contrast material used for IVP's, CT Scans, Venograms, or Arteriograms.
Have you ever been injected with X-Ray dye for any of the following procedures? I UNDERSTAND THAT THIS CONTRAST (LIKE MANY DRUGS) MAY CAUSE AN ALLERGIC REACTION.
I understand that my physician may have requested the use of a intravenous contrast media that will assist the radiologist in better distinguishing certain anatomy or abnormalities that would otherwise be difficult or impossible to see.
I understand that the procedure to be performed on me involves the use of x-rays, and possible inserting needles and iodine containing solutions (x-ray dye), which may enhance the diagnostic accuracy of the procedure. I understand that I may be receiving an intravenous contrast media and/or oral contrast media to enhance the visibility of certain tissues. Possible side effects may include, but not limited to, pain or swelling at the site of injection, nausea, vomiting, a warm flushed feeling, potential allergic reaction including, but not limited to hives, wheezing, difficulty breathing, and in rare instances, anaphylactic shock (severe allergic reaction). The purpose, benefits, and complications of the contrast procedure will be explained to my satisfaction before any injection takes place.
I hereby consent to any measure necessary to correct complications which may occur. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantee have been made to me concerning the results of this examination.
I confirm that the information I provided is complete and accurate to the best of my knowledge. I have read, understand, and consent to this CT examination.
Parent/ Guardian/ Authorized Person for minor FOR OFFICE USE ONLY
EDUCATION AND PREPARATION OF THE PATIENT FOR PROCEDURE TIME OUT BRIEFING: VERIFY PRIOR TO INJECTION PROCEDURE PROCEDURE DISCUSSED WITH PATIENT AND ALL QUESTIONS ANSWERED PATIENT UNDERSTANDS PROCESS INVOLVED AND ABLE TO PERFORM STUDY PATIENT HAS BEEN FASTING FOR THE APPROPRIATE LENGTH OF TIME PATIENT HAS TAKEN THE APPROPRIATE PREP FOR PROCEDURE Tech Signature:__________________________________________________

Source: http://baptist-new.webedge.mcmurry.com/Resources/10238/FileRepository/ctquestion.pdf

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