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CT / CYSTOGRAM / IVP / VCUG QUESTIONNAIRE / CONSENT FORM
NAME: _____________________________________ DATE OF BIRTH: _____________ SEX: M / F WEIGHT: _________ WHAT BODY PART IS TO BE EXAMINED? ________________________________________________________________ PLEASE DESCRIBE YOUR SYMPTOMS: __________________________________________________________________ HOW DID THIS OCCUR? ________________________________________________________________________________ WHEN DID THESE SYMPTOMS START? __________________________________________________________________ HAVE YOU HAD PRIOR IMAGING STUDIES? WHEN AND WHERE? _________________________________________ ___________________________________________________________________________________ HAVE YOU HAD PRIOR SURGERY FOR THIS BODY PART? WHEN AND WHERE? ____________________________ ___________________________________________________________________________________ DO YOU HAVE ANY EXISTING MEDICAL CONDITIONS? DESCRIBE: ________________________________________ ___________________________________________________________________________________ DO YOU SMOKE? YES/NO IF YES: HOW MUCH? _________________________ FOR HOW LONG? _____________ EX-SMOKERS: WHEN DID YOU QUIT? _________________________________________________ CURRENT MEDICATIONS: ______________________________________________________________________________ DO YOU HAVE ALLERGIES TO ANY MEDICATIONS? ______________________________________________________ MEDICAL HISTORY:
1. ASTHMA / HAY FEVER / TUBERCULOSIS……………………….……………………………Yes ( ) No ( ) 2. DO YOU HAVE ALLERGIES TO ANY OF THE FOLLOWING: X-ray contrast………………….……….…………………………….…………………….….…Yes ( ) No ( ) Iodine……………………………….…………….………………………….…………….…….Yes ( ) No ( ) Shellfish or food……………………….………….….…………………………….…………….Yes ( ) No ( ) Medications……………………………….………….………………………………….………Yes ( ) No ( ) Please list all medications you are allergic to: ____________________________________________________ What type of reaction if any? ___________________________________________________________________ 3. KIDNEY DISEASE……………………………………………….…………………….….…….Yes ( ) No ( ) 4. LIVER DISEASE / HEPATITIS……………………………….………………….…….….…….Yes ( ) No ( ) 5. HEART DISEASE / HIGH OR LOW BLOOD PRESSURE……………….…….……………….Yes ( ) No ( ) 6. DIABETES.……………………………………….……………………….…….………….……Yes ( ) No ( ) Are you taking any of the following medications (circle all that apply): Glucophage, Glucavance, Metformin, Metaglip, Glumetza, Fortamet, Avandamet, Riomet, Actoplusmet, Janumet, Jentadueto and/or Kombiglyze XR When did you stop taking this medication? _______________________________________________________ 7. HAVE YOU EVER HAD A CT / IVP / ANGIOGRAM WITH IV CONTRAST?.………………Yes ( ) No ( ) If yes, what happened? ______________________________________________________________________ 8. NPO / TIME OF LAST MEAL: _________________________________________________________________ 9. IF APPLICABLE – ARE YOU PREGNANT?……………………………………….…….……….Yes ( ) No ( ) 10. IF APPLICABLE – ARE YOU BREAST FEEDING?…………………………………………… .Yes ( ) No ( ) 11. AGE: _______ Office Use Only: BUN: _______ CREATININE: _______ CREATININE CLEARANCE: _______ I give my permission for Dr. Barek, associates or assistants of his choice, to perform a contrast study on myself. I understand this study may require the administration of required pharmaceuticals, which may be administered into a vein, or body cavity. The expected benefits, potential risks and possible consequences associated with the performance of this study have been thoroughly explained to me. With the IV contrast, I understand that I may experience a warm flushed feeling along with nausea/vomiting. The possible adverse reactions of IV contrast may include rash, hives, swelling, difficulty breathing and in very rare instances anaphylactic shock, along with the risk of contrast extravasation resulting in soft tissue injury. PATIENT SIGNATURE: _____________________________________________ DATE: ___________
*Authorized Rep: _____________________________ Relationship: _____________ Date: ___________
*Signature of person authorized to consent if patient is incompetent or minor.
Witness Signature: ________________________________ Radiologist: _______________________________ Effective 10/05/12

Source: http://www.metropolitandiagnostic.com/patient_forms/forms/CT-Cystogram-IVP-VCUG%20Questionnaire-Consent%20Form.pdf