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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.
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 _____

Source: http://imagegently.dnnstaging.com/Portals/6/Radiologists/IG_CT_Parent_Info_frm.pdf

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