Alexandriaradiology.com

CT Questionnaire & Consent 
Name: _______________________________________________ Age: __________________
Emergency contact (Name and Phone number): ________________________________________
Referring Physician: ______________________________________________________________
Reason for Exam: ______________________________________________________________________ 
1. Have you ever had a CT or CAT scan before? If yes, for what body part? ___________________________________________________ 2. Have you had IV Contrast for any type of study before? If yes, did you have any problems with the IV contrast? If yes, what kind of problems? ______________________________________________ If yes, please list them here: ________________________________________________ If yes, what type(s) of cancer? _______________________________________________ 5. Do you have a history of any allergies? If yes, please list them here: _________________________________________________
6. Do you have any breathing problems like asthma, COPD, etc.? 7. Are you taking any medications for diabetes? If yes, do you take Glucophage, Glucovance, Metformin or Avandamet? 8. Do you have a history of sickle-cell disease? 9. Do you have a history of multiple myeloma? 10. Do you have any serious health issues such as kidney problems/ failure, heart or liver disease? YES NO
If yes, please list them here: ________________________________________________ Your doctor may have you scheduled for a CT examination that requires the injection of a contrast agent into your bloodstream. The contrast is given through an IV needle placed into your vein. Normally, contrast material is considered quite safe. However, any injection carries a slight risk of harm including but not limited to: injury to nerve, artery or vein, infection, or a reaction to the contrast material. Occasionally, a patient will have a mild reaction to the contrast and develop sneezing or hives. Uncommonly (1 in 1,600), treatment may be required. The physicians and staff of the radiology department are trained to treat these reactions. Very rarely (1 in 170,000), death has occurred related to the contrast. Consent: I, the undersigned, on my behalf as the patient, or in my capacity as the legal representative for the patient, or as parent or the legal guardian for the patient, acknowledge and confirm that I have read and understood all the above explanation about the injection of the contrast material, if required, and I have had all of my questions answered. I understand that my insurance carrier may not cover the entire cost and that I will be responsible for any cost not covered by my insurance carrier. I voluntarily consent to the performance of the examination and the injection of the contrast, if required. Patient, Parent or Legal Guardian Signature: _______________________________    Date: _______________ 
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Type of IV contrast given: ___________________  Oral Contrast      YES     NO  If yes, where? ______________________________  Prior images available in PACS?  YES  Technologist signature:  ________________________________ 

Source: http://alexandriaradiology.com/sites/default/files/files/AAR%20web%20-%20your%20visit%20-%20patient%20exam%20forms%20-%20CT.pdf