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Wbnm patient questionnaire

Wide Bay Nuclear Medicine
PLEASE  C
ish MPLETE  THIS  F
ORM  AND  BRING  IT  WITH  Y
ANDRE  WHEN  Y
MRCP(UK), ME  
Independently owned
FOR  YOUR  SCAN.
Consultant Physicians in Nuclear Medicine Your  Name:  _________
PA_TI_E_N_T__
DE _T_AI_L_S___________________________________________________________
All Appointments
4151 6880
Are  you  allergic  to  anything  ?  
□  Yes   (Type  ____________________) Do  you  have  D
Appointment Details iabetes  ?  
If  yes,  what  type  of  treatment  ?   Time:  forget  to  adjTeu
hone  insulin  dose  on  morning  of  test  because  you  will  be  
fasting.  Also  bring  with  you  yoGu
(spe  cm
ify) onitoring  device  and  
usual  sugar  su
Bundaberg p
site plement.)
Have  you  ever
Hope Str  ha
d  a  heart  attack  ?  
Phone 4151 6880
GNOSTIC NUCLEAR MEDICINE
Do  you  suffer  from  chest  pain/an
loose pr gin
osthesis, a  ?  □
Thyroid nodules, goitre, all causes of hyperthyroidism, thyroiditis.
Do  you  use:  
Parath  yr □  G
Localisation of parathyr ches   □  An Assessment of myocardial ischaemia and viability. For patients unable to exercise dipyridamole or dobutamine (for asthmatics) are used.
Have  you  ever
Lung Scan  had  heart  surge
ry  ?  
entilation and perfusion-pulmonar     radiation than helical CTPA. Regional quantification. Right to left shunts.
Differential renal function, renovascular hypertension, ureteric obstruction Or  Angioplast
MAG3 is substituted in children. GFR quantification if requested.
ASSOCIATED SITE ?  
Renal scarring and acute pyelonephritis (more sensitive than ultrasound).
Differential function (particularly if one kidney is small or ectopic).
Do  you  have  an  
Nuclear Medicine
Gallium Scan irregular  heaLrt  beat  ?  
coidosis.       □  Not  sure Chronic infections, eg osteomyelitis and infected joint prosthesis.
Localisation of acute or subacute infection. Assessment of activity of Do  you  have  any  medical  condition
inflammator s  
el disease. could  prevent  you  from  exercising  
on  our  bicycle  ?
er nodules (FNH) pain  or  arthritis)   Haemangioma of the liver. Gastrointestinal haemorrhage.
Acute cholecystitis. Biliary obstruction or dysfunction.
CCK used for chronic cholecystitis or sphincter of Oddi dysfunction.
Do  you  hav
L e  asth
ymphoscintigra m
phy a  ?
Sentinel node localisation in breast cancer and melanoma. Assessment of Signature  
If  yes,  have  you  ever  been  hospitalised  with  asthma  ? Are  you  being  tr
BUNDABERG 4670 e
Gastric Emptying ated  for  High  Blo
Quantitativ od  Pressure  ?          □  No  
e assessment of solid gastric emptying using a labelled egg sandwich. Half clearance time and % retained at 3 hours ar Small and large bowel clearance using sequential images over 5 days.
Please  list  all  me
Lacrimal Scan dications  you  are  currently  taking Functional nasolacrimal duct obstruction.  (or  attach  list) Report to be
Returned with Patient
____________________________________________________________________________________________   NUCLEAR MEDICINE THERAPY
www.ncnm.com.au
____________________________________________________________________________________________ Palliative treatment of painful osteoblastic bone metastases.
ombocythaemia      □  No   If  yes,  who  is  your  local  Dr  _
(Can onl ____
y be pr ______
escribed b _______
y a specialist) ______________
Patient Preparation
If  you  are  u
! nsure  a
Bone Scan - w b
ell h out  
ydrated. any  o
Images perf f  the  questions  pl
ormed 2-3 hours after injection and tak ease  le
e up to 1 hour. ave  them  and  our  staff  
My will  h
elp  whe
dial perfusion scan (thallium,n  you  come
 for  your  appoin
or 3 hours after a light breakfast, then hav No tea or coffee for 24 hours. Omit betablockers for at least 24 hours.
More detailed written information is provided.
Biliary Scans (HIDA, HIDA/CCK) fast for 4 hours.
ter AFF USE O
y stenosis is being assessed A NLY
□ Fasting !
□ Caffe
Most other pr ine c
ocedur eas
eparation. nsulin dose adjusted
□ GTN Indicated
www.widebaynm.com.au
Wide Bay Nuclear Medicine
Established 1994
DR ANDREW SOUTHEE MBBS(Hons), MRCP(UK), FRACP Independently owned
Consultant Physicians in Nuclear Medicine PATIENT DETAILS How  to  Wind  us…
All Appointments
4151 6880
Appointment Details
Bundaberg site
Phone 4151 6880
osteonecrosis, RSD and tumour staging.
all causes of hyperthyroidism, thyroiditis.
Localisation of parathyroid adenoma using myocardial perfusion isotopes.
Assessment of myocardial ischaemia and viability. For patients unable to Ventilation and perfusion-pulmonary emboli. More sensitive and far less radiation than helical CTPA. Regional quantification. Right to left shunts.
Differential renal function, renovascular hypertension, ureteric obstruction MAG3 is substituted in children. GFR quantification if requested.
ASSOCIATED SITE
Renal scarring and acute pyelonephritis (more sensitive than ultrasound).
Differential function (particularly if one kidney is small or ectopic).
Nuclear Medicine
List  of  Com
Shop 2 46-48 Main Str m
Lymphoma staging and response to treatment. PUO. Sarcoidosis.
Chronic infections, eg osteomyelitis and infected joint prosthesis.
OR locker  Drugs  for  your  information
Localisation of acute or subacute infection. Assessment of activity of Haemangioma of the liver. Gastrointestinal haemorrhage.
Acute cholecystitis. Biliary obstruction or dysfunction.
Sentinel node localisation in breast cancer and melanoma. Assessment of Dementias and cognitive impairment and cerebrovascular diseaseat e assessment of solid gastric emptying using a labelled egg sandwich. Half clearance time and % retained at 3 hours are calculated.
Small and large bowel clearance using sequential images over 5 days.
Functional nasolacrimal duct obstruction.
Returned with Patient
NUCLEAR MEDICINE THERAPY
www.ncnm.com.au
Palliative treatment of painful osteoblastic bone metastases.
ycythaemia rubra vera and essential thrombocythaemia Patient Preparation
Bone Scan - well hydrated. Images performed 2-3 hours after injection and take up to 1 hour.
Myocardial perfusion scan (thallium, sestamibi)- fast for 3 hours after a light breakfast, then have clear fluids sparingly.
No tea or coffee for 24 hours. Omit betablockers for at least 24 hours.
vided.S PHONE: 4124 3580
Biliary Scans (HIDA, HIDA/CCK) fast for 4 hours.
Renal Scans - well hydrated. If renal artery stenosis is being assessed ACE inhibitors need to be reviewed.
Most other procedures have no special preparation.
www.widebaynm.com.au

Source: http://www.widebaynm.com.au/examinations/downloads/files/wbnm_patient_form.pdf