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University of Pennsylvania Health System and School of Medicine
Research PET Scan Protocol Form
PRESCRIPTION INFORMATION
Patient’s Name:
DOB:
MRN:
Pregnancy Test (Required for women < 55 years old with intact uterus):
Serum_____ Urine _____
Test not required because :
Male
Result _____________________ OR
Post-hysterectomy
Date_______________________
≥ 55 years old
Verified by ________________________________________
Radioactive compound to be administered:
If FDG, limiting blood glucose level?
mg/dl
Dose:
(range in mCi or concentration). Upper limit?
mCi
Diagnostic CT (PET/CT studies only) (Must be checked for CT to be performed)
IV Contrast Enhanced (Must be checked for IV contrast to be injected)
Scheduled Injecting Physician (for non-FDG radioisotopes):
Abass Alavi
Chaitanya Divgi
Andrew Newberg
Dan Pryma
_____________________________________
Physician Signature
Date
______________________________________
Printed Physician Name
PROTOCOL INFORMATION
Protocol Title:
IRB Protocol #:
PET Code:
Authorized User :
Principal Investigator:
Contact Info in case of questions:
Name:
__________________________ _____________
Res. Coordinator Signature
Date
IMAGING PARAMETERS DEFINED IN PROTOCOL
Uptake period (delay between injection and scanning):
Standard delay (60 min for wholebody, 30 min for brain)
No delay
Other delay:
min
Special instructions for injection and/or uptake period:
If PET/CT scan, Oral Contrast:
Form Version 6a
Yes
No
Last Modified: 27Jan10
Page 1 of 3
University of Pennsylvania Health System and School of Medicine
Research PET Scan Protocol Form
Scan Protocol: (Check only 1 scan type and 1 option under the scan type)
PET Brain Scan (Resource Code: PET3)
Cs-137 Transmission scan for Attenuation Correction
PET ONLY body scan (Resource Code: PET1)
Standard whole body: from mid-thigh to base of brain; Cs-137
Transmission scan for Attenuation Correction
Other (please specify):
PET/CT scan (Resource Code:
PET2 or
C202 or
Either)
Standard whole body: from base of brain to mid-thigh; Standard Low-Dose CT for
Attenuation Correction
Other: (please specify):
Additional Diagnostic CT Scan (Please fill out CT scan parameters on page 3)
Scan Duration:
Standard whole body time per bed position (based on BMI)
Fixed duration:
min/bed
Dynamic scan: # time points
, duration of each
min
Patient Positioning:
Supine
Prone
Additional comments about patient positioning:
Additional comments about image acquisition:
Form Version 6a
Last Modified: 27Jan10
Page 2 of 3
University of Pennsylvania Health System and School of Medicine
Research PET Scan Protocol Form
Additional images:
Second time point of (part of body):
(requires additional low-dose CT)
Other images:
Diagnostic CT: (NOTE: Diagnostic CT can be performed ONLY if the patient is
scheduled for a PET/CT scan, and the CT must be scheduled as a separate procedure.)
Scan Type: (Check all that apply in a single row)
Chest
Abdomen
Pelvis
Neck
Head
Other: ___________________________________
IV Contrast Enhanced:
Slice Thickness:
Yes
No
mm
mAs Setting:
kVp Setting:
Additional Scan Settings: (Rotation Time, Pitch, Filters, etc.)
Additional Comments:
Form Version 6a
Last Modified: 27Jan10
Page 3 of 3