Austin Radiological Association Patient History/Contrast Form
HAVE YOU HAD ANY PREVIOUS IMAGING STUDIES OF THE BODY PART BEING EXAMINED TODAY?
HAVE YOU EVER HAD?
Previous imaging that required an injection of contrast media/dye? If yes, did you have a reaction or experience any difficulties due to any imaging contrast/dye injection?
Surgery to the part of your body being examined today?
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
Angina pectoris (severe constricting chest pain)
Aortic valve disorders (mitral valve prolapse)
Primary pulmonary HTN (not High Blood Pressure)
Cardiac dysrhythmia (irregular heart beat)
Tachycardia (abnormally high heart rhythm rate)
Are you taking Glucophage? Glucovance? (Metformin)
Please list below all medications you are currently taking and all of your allergies (medicine, food or other):
I (we) understand that there may be a possibility I will need an injection and/or oral dose of contrast to complete my diagnostic exam. I (we) also understand there is a possibility that I may have an allergic reaction to the contrast and/or an extravasation of contrast into the surrounding tissues of where my intravenous catheter is placed. Both can be minor to severe. Reactions may include, but are not limited to: nausea, vomiting, warm sensation, altered taste, itching, hives, rash, headache, pallor, nasal stuffiness, dizziness, chills, swelling around the face and eyes, anxiety, tachycardia, hypertension, hypotension, shortness of breath, wheezing, laryngospasm, bronchospasm, anaphylaxis, convulsions, cardiopulmonary arrest and death. Extravasations (leakage into tissue) may be minor with small amounts of contrast, but can be severe if tissues react to the contrast. Large volume extravasations may possibly lead to surgical intervention. I (we) have read and understand the above information and give consent for the administration of intravenous contrast and/or oral contrast as indicated. Patient Signature:
TO BE COMPLETED BY TECHNOLOGIST/ARA PERSONNEL ONLY ON ALL CONTRAST EXAMS
Creatinine level_____________ GFR____________ Date_____________ Was patient pre-medicated for contrast allergy? Yes No BP ______________ Patient Fasting? Yes No IV access: Time: ____________ Location: ____________ Catheter size: ____________ Number of Attempts: ____________ Signature of employee starting IV: __________________________________________ Contrast type injected _____________ Volume __________ml. Lot# __________ Exp. Date __________ Time __________AM / PM Allergy problems post contrast? Yes No If yes, complete Contrast Incident Form. Signature of employee administering contrast agent: __________________________________________ IV removed with catheter intact? Yes No Signature of employee removing IV: __________________________________________
April 2007 Patient History/Contrast Media Form.doc – jjg rev 2/2010 MRI Patients Complete Reverse Side
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