PHYSICIAN’S ORDER SHEET



CONSENT FOR CONTRAST MEDIA / PATIENT SAFETY FLOW SHEET

Technologist to FULLY complete information below before proceeding with procedure:

Lab Values: BUN_______ Creatinine ________, Weight ________lb, Height ________Ft. ________In.

Contrast Type:____________________ Amount:____________ Date:________________ Time____________

No Reaction: Patient Tolerated Exam: Comments:_________________________________

Reaction: Describe:____________________________________________________________________

Technologist Signature_____________________________________ Date/Time:______________/_______

ERMD Review/Signature____________________________________ Date/Time:______________/_______

If OP, & labs abnormal, Call PCP: □ Cancel □ CT without contrast. ________Tech’s Initials

Consented By:__________ Scanned By:__________ Injected By:__________

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|B |Please answer the following questions so that we can evaluate if you are at risk for an adverse reaction to the contrast |Check |

| |material: |Yes or No or NA |

|1 | Have you ever had a reaction to iodine, x-ray dye, or any contrast? |□Yes □ No |

|2 |Do you have allergies to Barium Sulfate or Water-soluble Contrast agent (Gastrografin)? |□Yes □ No |

|3 |Do you have any food allergies (shrimp, nuts, etc): List foods:____________________ |□Yes □ No |

| |Type of reaction(s)?_____________________________________________________ | |

|4 |Are you diabetic? |□Yes □ No |

|5. |Are you taking the medication Metformin (Glucophage, Glucophage XR, Glumetza, Fortamet, Riomet, Metaglip, Glucovance, Actoplus |□Yes □ No |

| |Met, Actoplus Met XR, Prandimet, and Avandamet)? If so, when was your last dose? | |

|6. |Are you taking an aminoglycoside, such as gentamycin, Cyclosporin, Cisplation, tobramycin, amikacin or vancoymcin? If so, when |□Yes □ No |

| |was your last dose? | |

|7. |Do you have a history of food or liquid aspiration or difficulty swallowing? |□Yes □ No |

|8. |If you have hyperthyroidism, have you been taking your anti-thyroid medication regularly for the last 10 days? |□Yes □ No □NA |

|9. |Do you have a history of any recent abdominal biopsy or surgery? |□Yes □ No |

|10 |Female patients: |

| |Are you pregnant? □ Yes □ No. Are you nursing? □ Yes □ No. Date of last menstruation:___________ |

|11 |If you have any of the following conditions, please check all boxes that apply: |

| |□ Asthma |□ Glaucoma |□ Sickle Cell Disease |□ Chronic Lung Disease |

| |□ Angina |□ Blood Clots |□ Multiple Myeloma |□ Congestive Heart Failure |

| |□ Stroke |□ Rash/Hives |□ Difficulty Breathing |□ Heart Attack or Heart Disease |

| |□ Seizures |□ Kidney Problems |□ High Blood Pressure |□ Arrhythmia (irregular heartbeat) |

CONSENT FOR CONTRAST MEDIA

PATIENT SAFETY FLOW SHEET

CONSENT FOR CONTRAST MEDIA / PATIENT SAFETY FLOW SHEET – side 2

|C |Medication Allergy History |

| |□ No Known Drug Allergies / □ Allergy Info Not Available |

|12 |Please list all medication in which you have allergy |What reaction do you have with the medication |

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| |Medication List |

|D |□ See attached list, □ List not available Or Complete Medications List Below |

|13 |Please list all medications you take at home |Dose |

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Exam:_____________________________________________________________________________

Patient’s Informed Consent for CT Examination with Contrast Media/Contraindications and Risks:

Some individuals have allergic reactions to iodine-based solutions administered intravenously. These reactions are usually mild and can consist of itching, watery eyes and hives. Infrequently this reaction may be serious and even fatal reactions to intravenous iodine have occurred. In the event of a serious reaction, a hospital-based physician is available to administer appropriate medications for treatment.

Signature:____________________________________________________ ______________________

Patient Signature (or representative) State Relationship to patient Date / Time

Outpatient Discharge Instructions

By signature below, I acknowledge receipt of a copy of the following:

□ Following the procedure, immediately drink 16 ounces of water

□ As a result of your visit with us, there is no change in your home medications.

□ Hold Metformin for 48 hours post procedure. You must have your kidney function re-evaluated before you

resume your medication or obtain permission from your physician.

□ Other changes in home medications:____________________________________________

Signature:____________________________________________________ ______________________

Patient (or representative) Signature/Relationship to patient Date / Time

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