Patient Information-Contrast Patient Assessment Form printable pdf download

Name: _______________________________________________________ Today’s Date: ______________________________________________

Date Of Birth: ________________________________________________

Weight: ______________________________________________

Patient Medical History/Symptoms: ___________________________________________________________________________________________

Have you ever had a prior CT scan? If so: Where: _________________________ Year: ________________

Yes No

Have you had a contrast injection (e.g. x-ray dye) before? If yes, how many times? ________________

Yes No

Did you have a contrast reaction occur during a previous exam?

Do you take:

Glucophage

Glucovance

Metformin

Fortamet

Riomet

Glumetza

Actoplus-Met

Metaglip

Prandimet

Avandamet

Janumet

ALLERGIES:

Do you have general allergies (hay fever, dust, mold, dander, food)? _______________________________

Yes No

Do you have any drug allergies? If so, list: ________________________________________________________

Yes No

MEDICAL PROBLEMS: Have you had or do you have:

Yes No

Kidney (renal) disease?

Have you had radiation therapy or chemotherapy? If yes, when ____________________________________

Yes No

Diabetes?

Yes No

Myeloma/Pheochromocytoma?

Yes No

History of cancer?

Other

__________________________________________________________________________________________________

Prior surgeries and dates: __________________________________________________________________________________________________

RISK & COMPLICATIONS: Your physician has referred you for a test during which you will be required to have a peripheral IV

started and receive an injection of a non-ionic contrast material (e.g., x-ray dye) into a vein. Complications with the IV may occur

including, but not limited to, infiltration, extravasation, site infection, hematoma and/or phlebitis. Also, minor allergic reactions such

as pain at the injection site, hives, swelling, itching or skin rash are rare but may occur. These reactions may require medications,

but will usually disappear within a few minutes of the injection. More serious allergic reactions, such as low blood pressure,

problems breathing, anaphylactic shock, are rare occurrences and medication is readily available to treat these conditions. In spite

of every skill and effort made to avoid complications during the examination, occasional complications do occur.

______________________________________________________________________________________________________________________________

Pre-Examination Pregnancy Determination

For female patients of reproductive age (post menarche to menopause [e.g., age 12-50]):

1) What was the first day of your last complete menstrual period? Month: _________ Day: _________ Year: _________

2) To the best of your knowledge, are you pregnant? Yes

Not Sure

Patient /Guardian Signature: __________________________________________________ Date: ________________ Time: ________________

Verified by: Staff Signature: ___________________________________________________ Date: ________________ Time: ________________

Tech Other

Patient Information/Label

Contrast Patient

Assessment Form

*RADS*

21606RMC (11/12)

Patient Information-Contrast Patient Assessment Form

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