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Microsoft word - ms800 iodine contrast.doc

IODINE CONTRAST FORM
Your Doctor has ordered the following exam which uses Iodine Contrast material: CT IVP HSG T-Tube Cholangiogram Retrograde Pyelogram Cystogram Fistulagram Name: ______________________________________________________________ Account / SS #: _________________ Date of Birth: _______________ Reason for Exam: _________________________________________________________ Have you ever had previous imaging that required injection of contrast media/dye? _______________ ‰ Yes ‰ No
Have you ever had an allergic reaction to IV Contrast used in any imaging procedure (CT, MRI, X-Ray)? . ‰ Yes ‰ No Do you have any of the following?
Diabetes . ‰ Yes ‰ No
Asthma . ‰ Yes ‰ No
Heart disease/problems . ‰ Yes ‰ No
Lung disease . ‰ Yes ‰ No
Hypertension (High Blood Pressure) . ‰ Yes ‰ No
Chronic kidney disease . ‰ Yes ‰ No
Dialysis . ‰ Yes ‰ No
Renal (kidney) failure . ‰ Yes ‰ No
Multiple Myeloma . ‰ Yes ‰ No
Pheochromocytoma (Adrenal Gland Tumor) . ‰ Yes ‰ No
Are you taking Glucophage? Glucovance? (Metformin) . ‰ Yes ‰ No
Are you taking Avandament, Actoplusmet, Fortemet, Riomet, Glumetza, or Janumet? . ‰ Yes ‰ No
Contrast Reaction:
Allergic reactions to contrast (dye) are rare; however, severe reactions including fatal or life-threatening reactions can occur. We utilize non-ionic contrast, which is the safest available contrast material. During CT examinations, an automated power injector is used to infuse the contrast intravenously. Occasionally, extravasation (leakage of contrast into the tissues) may occur. I certify that I understand the risks and alternatives involved in this procedure, that I have been given an opportunity to have my questions answered and that I elect to proceed with the examination including IV contrast material. Patient Signature: __________________________________________________________ Date: __________________
TO BE COMPLETED BY TECHNOLOGIST/BAPTIST M&S PERSONNEL ONLY ON ALL CONTRAST EXAMS
Contrast Type Injected: ________________ Volume _________ ml. Lot#: ___________ Exp. Date: ______________ IV Access: Time: ____ Location: _______ Catheter Size/Type: ______________________ Number of Attempts: ______ IV Started By: ________________________________________ Injected By: ____________________________________ Allergy problems post contrast? ‰ Yes ‰ No If yes, complete Contrast Incident Form. Date Lab Drawn: _______________________________ Creatinine within normal limits: ‰ Yes ‰ No ‰ NA If no, Creatinine Level: ____________ B.U.N. Level: ____________ Comments: ________________________________________________________________________________________ _________________________________________________________________________________________________ Baptist M&S Staff Full Signature: _____________________________________________ Date: __________________

Source: http://www.baptistmsimaging.com/Files/Documents/CT/MS800_Iodine_Contrast.pdf

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