Microsoft word - ms800 iodine contrast.doc
IODINE CONTRAST FORM
Your Doctor has ordered the following exam which uses Iodine Contrast material:
CT IVP HSG T-Tube Cholangiogram Retrograde Pyelogram Cystogram Fistulagram
Name: ______________________________________________________________ Account / SS #: _________________
Date of Birth: _______________ Reason for Exam: _________________________________________________________
Have you ever had previous imaging that required injection of contrast media/dye?
_______________ Yes No
Have you ever had an allergic reaction to IV Contrast used in any imaging procedure (CT, MRI, X-Ray)? . Yes No
Do you have any of the following?
Diabetes . Yes No
Asthma . Yes No
Heart disease/problems . Yes No
Lung disease . Yes No
Hypertension (High Blood Pressure) . Yes No
Chronic kidney disease . Yes No
Dialysis . Yes No
Renal (kidney) failure . Yes No
Multiple Myeloma . Yes No
Pheochromocytoma (Adrenal Gland Tumor) . Yes No
Are you taking Glucophage? Glucovance? (Metformin) . Yes No
Are you taking Avandament, Actoplusmet, Fortemet, Riomet, Glumetza, or Janumet? . Yes No
Allergic reactions to contrast (dye) are rare; however, severe reactions including fatal or life-threatening reactions can occur. We utilize non-ionic contrast, which is the safest available contrast material. During CT examinations, an automated power injector is used to infuse the contrast intravenously. Occasionally, extravasation (leakage of contrast into the tissues) may occur.
I certify that I understand the risks and alternatives involved in this procedure, that I have been given an opportunity to have my questions answered and that I elect to proceed with the examination including IV contrast material.
Patient Signature: __________________________________________________________ Date: __________________
TO BE COMPLETED BY TECHNOLOGIST/BAPTIST M&S PERSONNEL ONLY ON ALL CONTRAST EXAMS
Contrast Type Injected: ________________ Volume _________ ml.
Lot#: ___________ Exp. Date: ______________
IV Access: Time: ____ Location: _______ Catheter Size/Type: ______________________ Number of Attempts: ______
IV Started By: ________________________________________ Injected By: ____________________________________
Allergy problems post contrast? Yes No If yes, complete Contrast Incident Form.
Date Lab Drawn: _______________________________
Creatinine within normal limits: Yes No NA If no, Creatinine Level: ____________ B.U.N. Level: ____________
Baptist M&S Staff Full Signature: _____________________________________________ Date: __________________
Ministry of Defence Schedule of Approved Procedures Research Ethics Committee These guidelines relate to all non-clinical research involving human participants undertaken, funded or sponsored by MOD. MoD personnel conducting non-MOD research, while attached to an organisation with its own arrangements for indemnity, ethical scrutiny and compensation, should observe local arrangement
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