CT Questionnaire
To assist the radiologist in interpreting your study and help the technologist perform the correct exam for you, please answer the following medical questions: 2. Is there any possibility that you are pregnant? 3. Have you ever had IV contrast (contrast media or X-ray dye) before? 4. Are you allergic to IV contrast (contrast media or X-ray dye)? Please list any allergies to medications or drugs: 5. Do you have a history of the following conditions? 6. Do you take Glucophage, Metformin, Glucovance, or Avandamet? 7. Last time you ate or drank anything other than the CT Prep: 8. Have you had any of the following tests that pertain to the area we are imaging today? 9. Please list any surgery you have had in or near the area we are imaging today.
10. Have you ever been diagnosed with cancer? If yes, in what part of your body? When were you diagnosed? 11. Have you had radiation therapy for cancer? PLEASE TURN OVER
Valley Diagnostic Imaging Services – Olympic Building You have been scheduled for a CT exam that may require an injection of a contrast material (X-ray dye) into your bloodstream. This material is injected through a small needle placed in a vein. It provides added diagnostic information that helps the radiologist interpret the CT images.
The contrast substance is considered quite safe. However, an injection carries a slight risk, including injuryto a vein, infection, or reaction to material being injected. Physicians and technologists at Valley DiagnosticImaging Services are trained to treat reactions to contrast material. Most reactions are quite mild, consistingof sneezing or hives. Serious reactions are uncommon (approximately 1 in 1,000). Very rarely (less than 1 in100,000) death related to contrast administration has occurred.
Certain patients are at greater risk for experiencing a reaction to the contrast material.
Patients who are at higher risk for adverse effects are people who: • have already had a moderate or severe allergic-type reaction to contrast material which required • have severe allergies, asthma, or hayfever• have severe or incapacitating heart disease• have diabetes or severe kidney disease• have multiple myeloma ***Warning: Use of Glucophage, Glucovance, Metformin, or Avandamet oral medications for diabetes, must be discontinued at the time of procedure. These drugs should not be taken again for at least 48 hours following your procedure and until your doctor ensures that your kidney function is normal.
If you have any questions, please ask the technologist performing your exam.
I hereby consent to the above described procedure to be performed by VDIS - Olympic Building. I have read the above information and my questions have been answered.
Patient Signature: ________________________________________ Date: _______________ Time: (or authorized representative) Relationship to patient: ____________________ Witness Signature: _______________________________________ Date: _______________ Time: 2. Technologist: ________________________________________ Radiologist: 3. Access Device Type: Intima/Insyte Needle Gauge: 22/20/18 Insertion Site: 4. Started By: _____________ Hub Scrubbed per protocol by: ______________ DC’d By:

Source: http://www.vrads.com/docs/CT_Questionnaire_IPV.pdf


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CLIENT NAME 1223 Street Name City, State, Zip 777-777-77777 [email protected] EDUCATION____________________________________________________________________ University of Chicago Graduate School of Business Chicago, IL 1991 - 1993 Dean’s List United States Military Academy West Point, NY 1980 - 1984 Presidential & Senatorial Nomine

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