Patient Information
Radiology
CT Safety Questionnaire
NAME: D.O.B. ID check:
ADDRESS:
HOSPITAL NO: Male / Female Yes No
1. Have you had a CT scan before?
If outside of the Warwickshire area, please state where and when.
2. Have you had an injection of contrast medium before?
3. Have you ever had an adverse reaction to an injection of contrast
medium?
If YES, please give details:
4. Do you have asthma or COPD?
5. Are you allergic to anything?
6. Do you have renal failure, see a kidney specialist, or have dialysis?
7. Do you have any of the following:
- Diabetes
- Sickle cell anaemia
- Myeloma
If YES, please ensure you are well hydrated before this procedure.
8. Do you take Metformin or Glucophage?
9. May we use your images for teaching purposes?
10. Do you have any of the following:
- Angina, heart failure or atrial fibrillation
- Untreated Glaucoma
- An enlarged prostate that causes urinary retention
- Megacolon, myasthenia gravis or paralytic ileus
11. Patients aged 12-55 years only
What date did your last period start? Date: ..........................
- Are you currently breastfeeding?
- Could you be pregnant?
I have read the information sent with my appointment letter. I understand the
nature, risks and benefits of this examination and wish to proceed.
Patient signature:…………………………… Date: …………………..
Radiographer/Radiology Assistant: ……………… Height/Weight: ……………
The Trust has access to interpreting and translation services. If you
need this Information in another language or format please ask and we
will do our best to meet your needs.
Radiology
CT Safety Questionnaire
NAME: D.O.B. ID check:
ADDRESS:
HOSPITAL NO: Male / Female Yes No
1. Have you had a CT scan before?
If outside of the Warwickshire area, please state where and when.
2. Have you had an injection of contrast medium before?
3. Have you ever had an adverse reaction to an injection of contrast
medium?
If YES, please give details:
4. Do you have asthma or COPD?
5. Are you allergic to anything?
6. Do you have renal failure, see a kidney specialist, or have dialysis?
7. Do you have any of the following:
- Diabetes
- Sickle cell anaemia
- Myeloma
If YES, please ensure you are well hydrated before this procedure.
8. Do you take Metformin or Glucophage?
9. May we use your images for teaching purposes?
10. Do you have any of the following:
- Angina, heart failure or atrial fibrillation
- Untreated Glaucoma
- An enlarged prostate that causes urinary retention
- Megacolon, myasthenia gravis or paralytic ileus
11. Patients aged 12-55 years only
What date did your last period start? Date: ..........................
- Are you currently breastfeeding?
- Could you be pregnant?
I have read the information sent with my appointment letter. I understand the
nature, risks and benefits of this examination and wish to proceed.
Patient signature:…………………………… Date: …………………..
Radiographer/Radiology Assistant: ……………… Height/Weight: ……………
The Trust has access to interpreting and translation services. If you
need this Information in another language or format please ask and we
will do our best to meet your needs.
