CT Parent Information Questionnaire and Protocol Form
Name ______________________________________________________ Medical Record # _______________________________
Age ___________ Sex: M r F r Weight ___________ Outpatient r Inpatient r Emergency r
We would like to plan the CT for your child/ you to obtain the best test possible. A radiologist is the doctor who will be reading (interpreting) your child's CT scan. Please tell the radiologist why the CT scan is being done today. Fill in:
Were you given written information about the CT scan, its risks and what to expect? Yes r No r Does you child have a known illness/ chronic illness? ___________________________________________________________ Prior surgery? List all. _______________________________________________________________ Year____________________ Has your child had a prior CT scan? No r Not sure r Yes r Please list all. Where?
___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ For girls, 12 years of age and older and is menstruating (has period) When was last period? ______________________ Is there a chance of pregnancy? Yes r No r Pregnancy test peformed? No r Yes r HcG r urine r or blood r? _________Date ____________________________ Does the patient have any allergies (dye or contrast material, food, medication, latex? No r Yes r If yes Please list: _____________________________________________________________________________________________ Does that patient have: -Kidney disease or kidney failure? No r Yes r If yes, please describe ________________________________________________________________________________________ -Liver disease or liver failure? No r Yes r -Blood disorder? No r Yes r -Diabetes? No r Yes r Has patient had IV (by vein) contrast in the last 48 hours? No r Yes r (CT or MRI) Is the patient on feeding by intravenous (TPN or Lipids) No r Yes r Is patient diabetic and on Metformin (Glucophage) No r Yes r
Please list medications patient is taking: _________________________________________________________________________________ ___________________________________________________________________________________________________
Patient/ Parent/ Legal Guardian_signature ______________________________________________ Date _________________
For radiology use only:
Radiologist to view prior to patient off scanner: Yes r No r Radiologist initials _______________
Head C- C+ C-/C+ High resolution scan r Lower resolution scan r Bone evaluation only r Special Instructions ___________________________________________________________________________________________
Neck C+ C- C-/C+ Special Instructions ___________________________________________________________________________________________
Chest C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Abdomen C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Pelvis C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Other C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Sedation: Yes r performed by radiology_____ anesthesia _____ other _____
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CT Parent Information Questionnaire and Protocol Form
Name ______________________________________________________ Medical Record # _______________________________
Age ___________ Sex: M r F r Weight ___________ Outpatient r Inpatient r Emergency r
We would like to plan the CT for your child/ you to obtain the best test possible. A radiologist is the doctor who will be reading (interpreting) your child's CT scan.