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    Patient Questionaire v1

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    api-358179847
    This document contains a health questionnaire for patients undergoing a CT coronary angiogram. It asks questions about allergies, medical conditions like diabetes and kidney disease, current medications, and history of cardiac issues. Answering accurately is important so the medical team can assess if iodine contrast can be used safely and optimize the test. Laboratory results for kidney function will also be reviewed before proceeding with contrast injection.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Questionaire v1

    Uploaded by

    api-358179847
    129 views2 pages
    This document contains a health questionnaire for patients undergoing a CT coronary angiogram. It asks questions about allergies, medical conditions like diabetes and kidney disease, current medications, and history of cardiac issues. Answering accurately is important so the medical team can assess if iodine contrast can be used safely and optimize the test. Laboratory results for kidney function will also be reviewed before proceeding with contrast injection.

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    patient questionaire v1

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    This document contains a health questionnaire for patients undergoing a CT coronary angiogram. It asks questions about allergies, medical conditions like diabetes and kidney disease, current medications, and history of cardiac issues. Answering accurately is important so the medical team can assess if iodine contrast can be used safely and optimize the test. Laboratory results for kidney function will also be reviewed before proceeding with contrast injection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    129 views2 pages

    Patient Questionaire v1

    Uploaded by

    api-358179847
    This document contains a health questionnaire for patients undergoing a CT coronary angiogram. It asks questions about allergies, medical conditions like diabetes and kidney disease, current medications, and history of cardiac issues. Answering accurately is important so the medical team can assess if iodine contrast can be used safely and optimize the test. Laboratory results for kidney function will also be reviewed before proceeding with contrast injection.

    Copyright:

    © All Rights Reserved
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    ST.

    GEORGE HOSPITAL
    DEPARTMENT OF NUCLEAR MEDICINE
    Gray St, Kogarah, NSW 2217
    Ph: 9113-3112 Fax: 9113-3991

    Health Questionnaire
    CT Coronary Angiogram
    Patient Details
    Name: MRN: Home ph:
    Work ph:
    Date of Birth: Age:

    Sex: Male Female

    Cardiologist:

    Contrast Questions:
    Background: Contrast material is used to help highlight the important cardiac structure we are about to
    examine, and to improve the accuracy of the test you are about to undergo. Certain medical conditions
    may influence the way you react to the contrast material and it is important for the team to know these
    medical conditions before you proceed with this CT scan.

    1. Are you pregnant or breastfeeding? Yes No

    2. Are you allergic to any medications? Yes No



    If so, what are they?

    3. Have you had any previous iodine based contrast or X-ray


    dye including CT scan, IVP/Kidney X-ray or angiogram Yes No

    Were there any problems? Yes No
    If so, please state

    4. Have you ever had any problems with your kidneys? Yes No
    If so, what were they?
    List medications you take for your kidneys.

    5. Are you being treated for diabetes? Yes No


    Do you take medications for diabetes? Yes No
    If so, please state
    Do you take Metformin? Yes No
    (Diabex, Glucophage or diaformin)

    6. Have you ever been diagnosed with any of the following conditions?
    Asthma? Yes No Myasthenia Gravis? Yes No
    Hyperthyroidism/Graves disease? Yes No Sickle cell disease? Yes No
    Thyroid Cancer? Yes No Kidney disease? Yes No
    Phaeochromocytoma? Yes No Hepatitis B or C Yes No
    ST. GEORGE HOSPITAL
    DEPARTMENT OF NUCLEAR MEDICINE
    Gray St, Kogarah, NSW 2217
    Ph: 9113-3112 Fax: 9113-3991

    Health Questionnaire
    CT Coronary Angiogram
    General Questions
    7. Do you have any of the following allergies? If yes, what type of reaction?
    Iodine/Contrast/Xray dye Yes No
    Latex Yes No
    Shellfish Yes No
    General allergies? If yes, to what?

    8. Which medications are you currently taking? (please attach a list if required)


    9. General health
    Do you currently smoke? Yes No
    Did you smoke in the past? Yes No
    If yes, for how long? < 12mths >12mths
    Do you have: diabetes? Yes No Type 1 Type 2
    High cholesterol? Yes No
    High blood pressure? Yes No
    Asthma/Airways disease? Yes No
    Do you exercise regularly (30mins 3x per week) Yes No
    Do you have a family history of heart disease? Yes No
    Are you post menopausal (females only)? Yes No

    10. Have you ever had:


    Any cardiac surgery? Yes No
    Type: Year: Where:
    A heart attack? Yes No Year:
    Abnormal stress test? Yes No Year:
    Coronary angiogram? Yes No Year:
    Stents placement/angioplasty? Yes No Year:
    Pacemaker implant? Yes No Year:

    11. This past week, have you had:


    Chest pain/angina/chest tightness/pressure? Yes No
    Heart palpitations? Yes No
    Shortness of breath? Yes No
    Patient to complete: Staff to complete:
    I have answered the above questions accurately
    to the best of my knowledge. I have no further Creatinine:
    questions. I wish to proceed with the contrast eGFR (ml/min):
    injection
    Patient signature: Physician signature:
    Patient name: Physician name:

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