Microsoft word - doctor testing form.doc

Patient’s Name: ___________________________________________________ Appointment Date: ___________________________Time: _______________ Exam: ______________________Referring MD: ________________________ Clinical Indication: ________________________________________________ Please bring with you to the appointment: WHICH MEDICATIONS YOU ARE TO TAKE THE DAY OF TEST DIABETICS: Please consult your physician regarding your diabetic medication Sestamibi Exercise Treadmill Test You will be in the office for approximately four hours. Wear comfortable clothing and sneakers or similar shoes. You should not eat anything for at least four hours prior to your test (you may drink water only). During the test you will exercise, and an intravenous infusion will be started. Images will be taken before and after exercise. Sestamibi Test with Persantine or Dobutamine You will be in the office for approximately four hours. Wear comfortable clothing. You should not eat anything for at least four hours prior to your test (you may drink water only). No caffeinated beverages for 24 hours prior to the test. An intravenous infusion will be started. Imaging will be done prior to and after infusion of the medication. Echocardiogram No special preparation. Exam will take 1 hour. DIRECTIONS CONTINUED ON BACK Stress Echo with Exercise or Dobutamine This test takes 1 hour. Wear comfortable clothing and shoes. If your test is schedule in the morning, please fast from midnight, but you may drink water. If your test is scheduled in the afternoon, you may have a light breakfast that day. You will walk on a treadmill and have ultrasound images taken of your heart. For those who can’t walk on the treadmill, an intravenous infusion will be started and a medication called Dobutamine will be infused. Exercise Treadmill Test Wear comfortable clothing and sneakers or similar shoes. You should not eat for 2 hours before the test. You may drink water. The test will take approximately 30 minutes. Holter Monitor/Event Monitor No special preparation. Wear a loose-fitting shirt or blouse. Holter recorders must be returned on the following day. Hookup on the day of the exam will take 15 minutes. Those patients with event monitors will be told when to return the monitors. Carotid Ultrasound No special preparation. Exam will take 45 minutes. Lower Extremity Non-Invasive Exam No special preparation. Wear comfortable clothing; bring shorts. Exam takes 45 minutes Cardiac MR (Providence location only) No special preparation. You may eat and take your usual medications. You will be asked questions to determine if you have any medical devices surgically implanted or if you have worked with metal. An intravenous line may be started if contrast will be used for your study. This test takes approximately 1 to 1 ½ hours. Cardiac CTA (Providence location only) No food or drink for 4 hours before your test. You may take your medications with sips of water only. If you take insulin, do not take any on the day of the test. If you take Glucophage (Metformin), stop taking it two days before your test. Your test will take approximately 30 minutes. Calcium Scoring (Providence location only) No preparation needed. Test takes approximately 10 minutes.

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