Microsoft word - 4 injection history sheet 09-15-2011.doc
INJECTION HISTORY SHEET
Brick CMCH EHT Festival Galloway Somers Point Wall Twp.
Name________________________________________ Date___________________ Age_________ LMP________Weight ________ Exam______________Referring Physician____________________ Why are you having today’s exam?______________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Have you had any recent prior CT, MRI, Ultrasound CT/PET, NM or endoscopy exams? Yes No If so, where and when:________________________________________________________________ Prior surgical and medical history:_______________________________________________________ ___________________________________________________________________________________________________________________________ List all medications:__________________________________________________________________ Level of Pain (1 – 10):_________ Have you ever had x-ray dye? Yes No _______________ Reaction? Yes No _______________ Are you pre-medicated with Prednisone/ Benadryl for today’s exam? Yes No IMPORTANT: If you are allergic to iodine (x-ray dye), please notify the technologist. Smoking History
No Yes __________________________________________________________________
Describe __________________________________________________
Do you take the following: Glucophage Metformin Riomet Glucophage XL Glucovance Metaglip Fortamet Janumet Avandamet Actoplus-met Glumetza
Multiple Myeloma No Yes The above medications must be stopped Sickle Cell Anemia No Yes for 48 hours AFTER this exam. Breast Feeding No Yes Cancer No Yes Chemotherapy No Yes Finished? No Yes When____________ Where____________ Radiation No Yes Have you had treatment since your last CT Scan? No Yes Myasthenia Gravis No Yes If yes, what type of treatment______________________________ Patient/Parent/Guardian Signature_______________________________________________________ - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Technologist Notes - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NON CONTRAST REASON_________________________________________________________________ Most Recent Labs: BUN ___________ Creatinine _______ as of ______________ None available CURRENT INJECTION: _______ cc OPTIRAY 300/320 OMNIPAQUE 180/300 ISOVUE 370 VISIPAQUE 320 Lot # _______________ Expiration Date_______________ Injected by:____________________________________ Site:______________ Angiocath :______g Reaction: No Yes Description _____________________________________________________ Dr. ________________________________________ was on the premises at the time of injection. (09/2011) # 4 Injection History Sheet.doc
Keweenaw Holistic Family Medicine Pediatric Intake FormParents marital status (circle): Married / Separated / Living Together / Other:Current Grade in School:Please indicate the severity of your symptoms by checking the box that applies to each symptom (sx). Part I: ENT - Allergy Symptoms Mild Moderate Severe Moderate Severe Moderate No Sx Mild Sx No Sx Mild Sx Severe Sx
INJECTION HISTORY SHEET