Sjra ct hx form vcontrast

CT Contrast History Form
Patient name ______________________________________________________ DOB ________________  Female  Male Weight _______________ Height __________________
1. Is there any chance of pregnancy?  Y  N Date of last menstrual period _______________________
2. Are you currently breast feeding?  Y  N
3. Why are you having this examination (medical problem) including symptoms: _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Do you have or have you been treated for the following: Lupus, Rheumatoid arthritis, Scleroderma 5. List all Allergies: _______________________________________________________________________ _____________________________________________________________________________________ 6. Please list all current medications taken: ____________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. Have you had a radiologic study / x-ray relating to this study?  Y  N If yes, when / where:
___________________________________________________________________________________ 8. Have you ever had an injection of IV contrast?  Y  N
9. Have you ever had any major surgery?  Y  N If yes, what / when:
_____________________________________________________________________________________ _____________________________________________________________________________________ 10. Are you currently taking any of the following medications?  Y  N
Avandamet, Glucophage, Glucophage, X-R, Glucovance, Metaglip, Riomet, Fortamet, Metformin, or any other medication containing Metformin? If so, these medications MUST be withheld 48 hours after the day of injection of IV contrast. Your physician
has been notified and he/she should have contacted you with instructions.
11. Are you or have you ever been a smoker?  Y  N If yes and you have quit, when? ______________
12. Have you had steroid prep?  Y  N
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Patient name __________________________________________ By explanation, the injection of organic iodine compound is necessary to study your internal organs properly. Everyone experiences a variety of sensations from warmth to “a real hot feeling.” Patient may experience: B. throat sensation, including nausea and wheezing C. general abdominal reactions including nausea/vomiting and/or a sense of an urgency to urinate. Some patients may experience a variety of these in combination. Typically, these are transient. We may need to treat these reactions if necessary. In the vast majority of
patients, these symptoms subside within one or two minutes. On occasion, more severe reactions may occur
that can be fatal or life threatening and require further treatment, such as medication and hospitalization.
The patient has been advised of possible reactions.

I have read and understand and all my questions have been answered.
Your doctor has requested this procedure that requires IV contrast because he/she feels the potential benefit
of the study outweighs the risk. If you have any further questions, please ask.
Patient Signature _______________________________________________ Date _________________
FOR OFFICE USE ONLY
eGFR __________________ Creatinine ____________________ Date Drawn _________________ Injected _________________________ cc _______________ @ _______________ am / pm Technologist ___________________________________________________________________________

Source: http://www.sjra.com/wp-content/uploads/2012/04/CT-Scan-Hx-Form-Contrast.pdf