CT Parent Information Questionnaire and Protocol Form
Name ______________________________________________________ Medical Record # _______________________________
Age ___________ Sex: M r F r Weight ___________ Outpatient r Inpatient r Emergency r
We would like to plan the CT for your child/ you to obtain the best test possible. A radiologist is the doctor who will be reading (interpreting) your child’s CT scan. Please tell the radiologist why the CT scan is being done today. Fill in:
Were you given written information about the CT scan, its risks and what to expect? Yes r No r Does you child have a known illness/ chronic illness? ___________________________________________________________ Prior surgery? List all. _______________________________________________________________ Year____________________ Has your child had a prior CT scan? No r Not sure r Yes r Please list all. Where?
___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ ___________________________________________________________ ____________________________ For girls, 12 years of age and older and is menstruating (has period) When was last period? ______________________ Is there a chance of pregnancy? Yes r No r Pregnancy test peformed? No r Yes r HcG r urine r or blood r? _________Date ____________________________ Does the patient have any allergies (dye or contrast material, food, medication, latex? No r Yes r If yes Please list: _____________________________________________________________________________________________ Does that patient have: -Kidney disease or kidney failure? No r Yes r If yes, please describe ________________________________________________________________________________________ -Liver disease or liver failure? No r Yes r -Blood disorder? No r Yes r -Diabetes? No r Yes r Has patient had IV (by vein) contrast in the last 48 hours? No r Yes r (CT or MRI) Is the patient on feeding by intravenous (TPN or Lipids) No r Yes r Is patient diabetic and on Metformin (Glucophage) No r Yes r
Please list medications patient is taking: _________________________________________________________________________________ ___________________________________________________________________________________________________
Patient/ Parent/ Legal Guardian_signature ______________________________________________ Date _________________
For radiology use only:
Radiologist to view prior to patient off scanner: Yes r No r Radiologist initials _______________
Head C- C+ C-/C+ High resolution scan r Lower resolution scan r Bone evaluation only r Special Instructions ___________________________________________________________________________________________
Neck C+ C- C-/C+ Special Instructions ___________________________________________________________________________________________
Chest C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Abdomen C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Pelvis C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Other C+ C- C-/C+Special Instructions ___________________________________________________________________________________________
Sedation: Yes r performed by radiology_____ anesthesia _____ other _____
Merkblatt zum Kopflausbefall in Gemeinschaftseinrichtungen in der Gemeinschaftseinrichtung, die Ihr Kind besucht, sind Kopfläuse aufgetreten. Vielleicht ist Ihr Kind sogar selbst betroffen. Kopflausbefall ist lästig und unangenehm. Bei engem Kontakt ist die Gefahr einer Weiterverbreitung durch das Überwandern der Läuse von Kopf zu Kopf bzw. gelegentlich über die Kleidung sehr groß. Um die
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CT Parent Information Questionnaire and Protocol Form
Name ______________________________________________________ Medical Record # _______________________________
Age ___________ Sex: M r F r Weight ___________ Outpatient r Inpatient r Emergency r
We would like to plan the CT for your child/ you to obtain the best test possible. A radiologist is the doctor who will be reading (interpreting) your child’s CT scan.