RADIOLOGY CONTRAST EVALUATION
Procedure: ______________________________________________
Creatinine: _______________________________________________
Do you have any history of Allergies (medication or foods) or Asthma?
Comments: __________________________________________________________________________________________________________________________________
Do you have any history of Heart Conditions?
Comments: __________________________________________________________________________________________________________________________________
Do you have any history of Chronic or Debilitating Conditions? Do you take Glucophage, Glucophage XR, Glucovance, Avandamet, Metaglip, Riomet, Altimetformin, Metformin, Glumetz R Apometformin, Genmetformin, Glycon, Novometformin, Numetformin, Pmsmetformin, Rhometformin, Rhoxalmetformin, Fortamet?
ORDER HISTORY:Have you ever been diagnosed with cancer?
If yes, describe: _______________________________________________________________
If yes, have you had radiation or chemotherapy?
When did you finish treatments? ________________________________________________
Have you had any previous surgery in the area that you are having scanned today?
If yes, when? __________________________________
Describe your surgeries: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you had any previous diagnostic exams for same area that you are having scanned today?
Describe (MRI, CT Scan, Nuclear Medicine, X-Rays, Ultrasound, Lab Work): ______________________________________________________________________________________________________________________________________________________________________________________________________________________
Why are you having this exam today? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Female Patients: Is there any possibility that you may be pregnant or nursing?
Date of Last Menstrual Period: __________________
Explanation about the nature of my procedure has been discussed with me. My questions have been answered and I consent to receive the contrast agent.
Signature of Patient/Guardian: ___________________________________________________________
Date: _________________________________________
If yes, describe: ________________________________________________________________________________________
Type/amount contrast administered: ______________________________________________________
IV Location ____________________________________
Signature of Technologist: _______________________________________________________________
IHHS Health & Wellness Center 1607 South H Street, Bakersfield, CA 93304 Hormonal, Homeopathic, & Nutritional Services Office (661)-837-0453 FAX (661)-837-0560 Benefits of Estrogen Replacement Bone Prevention of Osteoporosis and bone fractures [Treatment should be initiated at menopause and not 4 to 5 years later to be most effective] Heart Prevention of heart disease b
Effectiveness of Leech Therapy in Osteoarthritis of the Knee A Randomized, Controlled Trial Andreas Michalsen, MD; Stefanie Klotz, RN; Rainer Lu¨dtke, PhD; Susanne Moebus, PhD, MPH; Gu¨nther Spahn, MD; and Gustav J. Dobos, MD Background: Leech therapy was commonly used in traditional arthritis Index and physical sum score of the Medical Outcomes medicine for treating localized pain.