UT Southwestern Medical Center



Research Participant Questionnaire – To be completed by Research Coordinator

Height: _________ Weight: _________ Age: ________ Gender: ________

|Have you have a history of kidney disease? |Yes No |

|Have you ever had surgery related to your kidneys? |Yes No |

|Do you have a history of liver disease? |Yes No |

|Do you have high blood pressure? |Yes No |

|Do you have a history of heart disease? |Yes No |

|Do you have a history of seizures? |Yes No |

|Do you have a history of diabetes or currently diabetic? |Yes No |

|List any medications (prescribed or over-the-counter) that you currently take: | |

| | |

| | |

|Are you allergic to any food or medications? If yes, please describe. |Yes No |

|Do you have a medical diagnosis of sickle cell anemia? |Yes No |

|Have you ever received IV contrast dye in the past? |Yes No |

| If yes, has it been within the last 48 hours? |Yes No |

| If yes, did you have a reaction to the contrast dye? |Yes No |

|Do you have a history of asthma or hay fever? If yes, please explain. |Yes No |

|For Female Subjects: | |

|Are you pregnant, suspect you are pregnant, or experiencing a late menstrual period? |Yes No |

|Are you currently breastfeeding? |Yes No |

|What was the first day of your last menstrual period? _____________ |Urine hCG Result (circle): |

|(If not within 10 days of contrast date, urine pregnancy test required) |POSITIVE NEGATIVE N/A |

|**PHYSICIAN MUST BE AVAILABLE IN CLEMENTS BUILDING IN CASE OF EMERGENCY OR ADVERSE REACTION** |

|Physician Name: _______________________________________ |

|Phone Number/Pager: __________________________________ |

Screening Personnel: _________________________________________

(Print Name)

Signature of Screening Personnel: ___________________________________________ Date: _______________

To be completed by AIRC Staff

Serum Creatinine Level: _________mg/dl Calculated eGFR: _________ ml/min/1.73m2 Date Drawn: ____________

Reported By: Research Nurse Physician Other (specify): _________________________

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| |Time/Initials |

|IV Access | |

|IV Site: __________________ Type & Gauge: ___________________ # of Attempts: ______ | |

|Good blood return: Yes No | |

|Capped, dressed & secured: Yes No | |

|Flushes easily with normal saline: Yes No | |

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| | |

|Contrast Administration | |

|Type of Contrast Used: _________________________________ Dosage: ___________ | |

|Lot#: _______________ Expiration Date: ________________ | |

|Power Injector _______ml/sec IV Push _______ml/_______sec | |

|Amount of Saline Flush: ____________ml | |

|Signs/Symptoms of Extravasation at IV Site: Yes No | |

ADVERSE REACTION (most common in bold)

**If yes, please specify and describe treatment given below.

|Cardiovascular: tachycardia, hypotension, hypertension, bradycardia, chest pain |Yes No |

|Respiratory: throat constriction, shortness of breath, difficulty breathing |Yes No |

|Nerve: tingling in arms, faintness, pain, burning sensation |Yes No |

|Gastrointestinal: nausea, vomiting |Yes No |

|Skin/Body: rash, itching, flushing, hot flashes, fever, chills, excessive sweating, back spasm |Yes No |

|Other: warmth, nasal congestion, visual disturbances |Yes No |

Additional Notes: ____________________________________________________________________________

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Research Staff:

____________________________ /____________________________ Initials: _______ Date: ________________

(Print Name) (Signature)

____________________________ /____________________________ Initials: _______ Date: ________________

(Print Name) (Signature)

____________________________ /____________________________ Initials: _______ Date: ________________

(Print Name) (Signature)

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