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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: __________________
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