Patient questionnaire_layout

Patient Name______________________________________ Requisitioning Physician______________________________________ Age_________ Sex__________ Room Number__________BUN_________________________CR____________________________ Exam Requested_____________________________________________________________________________________________ Reason for Exam_____________________________________________________________________________________________ ___________________________________________________________________________________________________________ Clinical Information____________________________________________________________________________________________ PREVIOUS SURGERY
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Where ______________________________________________________ Where ______________________________________________________ ______________________________________________________ CONTRAST QUESTIONNAIRE
Do you take Glucophage,Glucovance or Metformin? INSTRUCTIONS
The patient is on Glucopange, Glucovance or Metformin and was given IV contrast media. The patient does not need to take this medication for 48 hours from the time of the X-rays or CT scan. Contact the family physician for further instructions.
1. CONTRAST:
A. None _________________________________________ F. 50 c.c Omipaque 350__________________________________ B. 50 c.c. Omnipaque 240 ___________________________ G. 50 c.c. Omnipaque 350 ________________________________ C. 100 c.c. Omnipaque 240 __________________________ H.100 c.c. Visipaque 270 _________________________________ D. 50 c.c. Omnipaque 300 ___________________________ I. 100 c.c. Visipaque 320 _________________________________ E. 100 c.c. Omnipaque 300 __________________________ J. Other ______________________________________________ Radiologist_______________________________________ Technologist _____________________________________ Chart Checked by _________________ Patient Scanned by _____________________________ Film Checked by _______________ Technologist Signature __________________________________________ Patient Signature ________________________________ Have you ever had an injection of contrast material? (“X-ray dye”)? Have you had any allergic reactions to contrast material? Are you allergic to any medications other than penicillin? If yes, please list: __________________________________ Do you take oral medications for your diabetes? If so, please list ___________________________________ Have you ever been admitted to a hospital for asthma? Have you had a recent sickle cell crisis? Do you have uncontrolled high blood pressure? Are you pregnant or is there any possibility that you may be pregnant? TECHNOLOGIST
Creatinine level __________________________________________________ Allergies listed in CPRS ___________________________________________________ _______________________________________________________________________ Any medications listed in CPRS that contain metformin? Includes: Metformin, Glucophage and Glucovance Patient Signature _____________________________________ Technologist Signature _____________________________________ Date ___________________ Time ______________________

Source: http://www.goodshepherdrehab.org/sites/goodshepherdrehab.org/files/documents/Patient%20Questionnaire_Layout%201.pdf