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Microsoft word - consent_mps

Dr Geoff Bower
Patient History for HEART SCANS (Myocardial Perfusion Studies)

Patient Name: ___________________________________ Date of birth: _____________________
Address: ________________________________________________________________________
Telephone Home: ______________ Mobile: _____________________ Work: _________________
Name of contact person in case of emergency: ________________ Telephone: ________________
For female patients only - is there any chance you may be pregnant?
- are you breastfeeding? Yes / No
- are you taking an oral contraceptive pill
Prior Heart Scan? Yes / No If yes, when and where: _________________________________
Why has your doctor referred you for a heart scan? (e.g. chest pain, recent heart attack, etc) _____
_______________________________________________________________________________
Have you ever had a heart attack?
If yes, when: __________________________
Have you ever smoked? Yes / No
If yes, when did you stop smoking? __________________
Do you experience chest pain or discomfort? Yes / No
Do you experience breathlessness?
Do you have a family history of heart problems? _______________________________________________________________________________ Do you have diabetes? If yes, how is it controlled? (e.g. pills, injections) _________
Do you have any problems walking or cycling? Yes / No
If yes, please describe (e.g. calf pain, angina, shortness of breath, arthritis, etc) ___________________________________________
Please list ANY previous surgeries: ___________________________________________________
_______________________________________________________________________________
Please list ANY past medical conditions: _______________________________________________
_______________________________________________________________________________
Please list ALL current medications: __________________________________________________
_______________________________________________________________________________
Please list ANY allergies: (e.g. sulphur, nitrates, drugs, etc) ________________________________
_______________________________________________________________________________
For male patients only: Are you currently being treated with Viagra?
STRESS HEART SCAN
Exercise testing measures the ability of the heart and lungs to function under a gradually increasing load. In most cases, the test is carried out for diagnosis or assessment of the severity of coronary artery disease. An intravenous injection line is inserted in an arm vein before testing commences. A resting electrocardiogram is recorded prior to exercise. The test is performed on a treadmill or an exercise bike. A drug called dipyridamole may be used to simulate the effects of maximum exercise. This may have some effects such as flushing, chest pain and headache, but these are usually short-lived and minimized by walking on the treadmill (during injection over four minutes). The effects of dipyridamole are reversed with another drug, a few minutes after the isotope is given.
Clinical exercise stress testing is usually performed in patients with known or suspected coronary
artery disease. While every effort is made to minimize the risk of the procedure, there is a very small
but definite risk of complications.
Possible complications include heart attack. The risk of this occurring is approximately 2 per 10,000
tests, or once in 15 years if you were to have this test every day. Unfortunately, there is also a very
small risk of death occurring as a result of the exercise test. The chance of this in the average
patients is less than 1 in 10,000. This needs to be weighed against the risk of not having the test, as
undiagnosed coronary artery disease may pose a much greater risk. In people with a recent stoker
(or other brain/ nervous problem) the test may need to be delayed. Speak to your specialist about
this.
Throughout the test a doctor is present, and the patient’s pulse, blood pressure and
electrocardiogram (ECG) are monitored. Emergency equipment and trained personnel are available
to deal with any complications that may arise.
I have read this form, understand the purpose and the risks of the tests, and consent to the
test being performed.
_________________________________

Source: http://www.isotope.com.au/files/nrteUploadFiles/82F082F201333A373A35PM.pdf

Authorization form (yellow form)

WASHINGTON DC/GETTYSBURG TRIP LIABILITY AND MEDICAL RELEASE AND AUTHORIZATION (YELLOW FORM) I, _____________________________, the parent of ____________________________ accept full responsibility for my child’s actions and behavior while on the Washington DC trip. In no way, will I hold the chaperones responsible or liable for any damages, accidents, injuries or losses that may oc

people.hamilton.edu

Adam W. Van Wynsberghe1063 Science CenterVisiting Assistant Research Scientist (Sabbatical Leave from Hamilton College)University of California-San DiegoDepartment of Chemistry and BiochemistryAssistant ProfessorHamilton College, Clinton, NYDepartment of ChemistryNIH Post-Doctoral FellowUniversity of California-San DiegoDepartment of Chemistry and BiochemistryAdvisor: Dr. J. Andrew McCammonAss

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