CT And IV Contrast History and Screening Form

Complete this before your appointment and your provider can be better prepared during their time with you.

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

Are you pregnant

Yes No N/A

Last Menstrual Period

Reason you are here today

Do you have pain?

Yes No

Have you had any surgeries in the area(s) that are being imaged today?

Yes No

Have you taken any medication/sedation/alchol todaady to help you relax for this procedure?

Yes No

Have you haad a previous exam related to this problem?

Yes No

If yes, please explain

Are you taking Metaformine Hydrochloride (Glucophage, Glucovance)?

Yes No

Have you ever had a previous allergic reaction to x-ray contrast (dye)?

Yes No

Do you have any of the following?

Please explain for each "yes" above

List any drug allergies

List all surgeries in your lifetime

List all medications you are currently taking

List all locations of your pain or symptoms on your body

List all locations of any metal in your body

Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that at this time I am pregnant OR NOT pregnant.

Initial

Patient/Parent/Legal Guardian Signature

Computerized Tomoraphy (CT) Consent Form

You have the right to be informed about the recommended diagnostic procedure to be used, so that you may make the decision whether or not to undergo this procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you can choose to give or withhold your consent to the procedure.
If you are pregnant or think you may be pregnant, please inform center personnel at once.
Your physician has requested a Computerized Tomography (CT) examination to obtain additional information. This is a diagnostic test that involves x-ray images and computers to produce an image of internal body parts.
As part of your CT, a contrast agent may be injected into your vein in order to produce better images of the part of the body being examined.
Potential Risks: The following complications are possible anytime an injection is given: potential for pain, bleeding, bruising or swelling at the injection site. CT exams requiring contrast may result in: mild headache, nausea, itching or other vague symptoms for a short time after the injection. Additional allergic reactions in response to the contrast agent may include: hives, shortness of breath or difficulty in swallowing. There have been rare instances of death after the administration of the contrast agent. It is very important that you inform the technologist if you experience any of the conditions mentioned in this form.
If you have previously had a reaction to a contrast injection such as hives, shortness of breath, any significant reaction requiring hospitalization, a history of asthma or other allergic conditions, any history of anemia, sickle cell anemia or kidney disorder; or if you are breastfeeding you must inform the technologist. The safety of contrast in children under 2 has not been established.
The diagnostic test being performed was ordered by your physician based on your symptoms and condition. The benefits of this exam are to assist your physician with a diagnosis.
In conjunction with the American College of Radiology (ACR) guidelines, it is the policy of One Step Diagnostic to identify patients at risk of developing Nephrogenic systemic fibrosis (NSF) prior to any Gadolinium-Based Contrast Agent (GBCA) injection. The method used to identify such patients require assessing renal function at the time of service.
Using a point of service device, a serum creatinine level is acquired and used to calculate the current estimated Glomerular Filtration Rate (eGFR). If provided, you and/or your insurance company will be billed for this service.

I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ IT, OR HAVE HAD IT READ TO ME (US), THAT THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS. I (WE) HAVE SUFFICIENT INFORMATION REGARDING THE PROCEDURE(S), THE RISKS, AND THE HAZARDS INVOLVED.

Patient Name Printed

Claustrophobic: Y or N

Allergic to Iodine: Y or N

Pregnant/Breastfeeding: Y or N

Kidney Problems: Y or N

Pacemaker/Metal /Implants/Pain Pumps/Neurostimulator/Stents:

Does PT have an implant card? Y or N

Visitor Screening Questionnaire

Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N

Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID-19 has been diagnosed or suspected: Y or N

Within the past 14 days, I have been sick with a cold or flu: Y or N

Within the past 7 days, I have had a fever: Y or N

Within the last 7 days, I have had nausea and vomiting and/or loss of taste and /or smell: Y or N

Within the last 7 days, I have had diarrhea: Y or

I now have symptoms of a cold or flu: Y or N

I now have a fever: Y or N

Within the past 14 days, I have been around people who have been or are sick with colds or flu: Y or N

I have been nauseated or have vomited or had diarrhea within the past week: Y or N

I have received the COVID-19 Vaccination: Y or N - if yes, please indicate which arm.

Identification Card: Please upload your picture ID card.

Please review to ensure the details are correct before completion.

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