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Ara-ct/mri patient history form

Austin Radiological Association
Patient History/Contrast Form

HAVE YOU HAD ANY PREVIOUS IMAGING STUDIES OF THE BODY PART BEING EXAMINED TODAY?

HAVE YOU EVER HAD?
Previous imaging that required an injection of contrast media/dye? If yes, did you have a reaction or experience any difficulties due to any imaging contrast/dye injection? Surgery to the part of your body being examined today?
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
Angina pectoris (severe constricting chest pain) Aortic valve disorders (mitral valve prolapse) Primary pulmonary HTN (not High Blood Pressure)
Cardiac dysrhythmia (irregular heart beat) Tachycardia (abnormally high heart rhythm rate) Are you taking Glucophage? Glucovance? (Metformin) Please list below all medications you are currently taking and all of your allergies (medicine, food or other): I (we) understand that there may be a possibility I will need an injection and/or oral dose of contrast to complete my diagnostic exam. I (we) also understand there is
a possibility that I may have an allergic reaction to the contrast and/or an extravasation of contrast into the surrounding tissues of where my intravenous catheter is
placed. Both can be minor to severe. Reactions
may include, but are not limited to: nausea, vomiting, warm sensation, altered taste, itching, hives, rash, headache,
pallor, nasal stuffiness, dizziness, chills, swelling around the face and eyes, anxiety, tachycardia, hypertension, hypotension, shortness of breath, wheezing,
laryngospasm, bronchospasm, anaphylaxis, convulsions, cardiopulmonary arrest and death. Extravasations
(leakage into tissue) may be minor with small amounts of
contrast, but can be severe if tissues react to the contrast. Large volume extravasations may possibly lead to surgical intervention.

I (we) have read and understand the above information and give consent for the administration of intravenous contrast and/or oral contrast as indicated.
Patient Signature:
TO BE COMPLETED BY TECHNOLOGIST/ARA PERSONNEL ONLY ON ALL CONTRAST EXAMS Patient MRN________________________
Creatinine level_____________ GFR____________ Date_____________
Was patient pre-medicated for contrast allergy? Yes No BP ______________ Patient Fasting? Yes No
IV access: Time: ____________ Location: ____________ Catheter size: ____________ Number of Attempts: ____________
Signature of employee starting IV: __________________________________________
Contrast type injected _____________ Volume __________ml. Lot# __________ Exp. Date __________ Time __________AM / PM
Allergy problems post contrast? Yes No If yes, complete Contrast Incident Form.
Signature of employee administering contrast agent: __________________________________________
IV removed with catheter intact? Yes No
Signature of employee removing IV: __________________________________________
April 2007 Patient History/Contrast Media Form.doc – jjg rev 2/2010 MRI Patients Complete Reverse Side

Source: http://gator1440.hostgator.com/~dbrannan/wp-content/uploads/Patient-History-Contrast-Form-March-2010.pdf

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