Transcription of Intravenous Injection of Iodinated Contrast Screening
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Intravenous Injection of Iodinated Contrast Screening
100555 (Rev2021-11)Last Name (Legal)First Name (Legal)Preferred Name Last FirstDOB(dd-Mon-yyyy)PHNULI Same as PHNMRNA dministrative Gender Male Female Non-binary/Prefer not to disclose (X)Page 1 of 2 Intravenous Injection of Iodinated Contrast ScreeningImportant - Form is used for regular and downtime use. Bold and italicized fields contain critical data elements that must be reconciled for if patient is unable to be screened, then obtain information from the referring Questionnaire ( )Weight _____ lb / _____ kgHeight _____ cm / _____ inchesQuestionsYesNoFurther InformationIs there a possibility you could be pregnant?Start date last menstrual cycle (dd-Mon-yyyy) _____oHysterectomyoMenopauseDo you have any allergies?If yes, list and describe:Have you had a previous X-ray Contrast Injection ( CT, Angiogram or Venogram, Intravenous Pyelogram - IVP)If yes, What: Where: When:Have you ever had an allergic reaction to X-ray Contrast ?
Intravenous Injection of Iodinated Contrast Screening Important - Form is used for regular and downtime use. Bold and italicized fields contain critical data elements that must be reconciled for downtime. oCheck if patient is unable to be screened, then obtain information from the referring physician.
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