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MOUNT SINAI RADIOLOGY
INTRAVENOUS IODINATED CONTRAST:
INFORMATION & QUESTIONNAIRE
Patient Name:
Date of Birth:
Medical Record Number:
Age:
Weight:
Type of Examination:
Your doctor has ordered a CT scan or X-ray examination which requires you to have contrast material (dye) injected
into your blood vessels to see certain parts of your body better during the procedure. This will allow the radiologist to
make a more complete interpretation of your test.
Contrast material is a clear fluid that contains iodine. It is injected at a carefully controlled rate by a computerized
injector. With the injection some patients feel warmth through their body or sense a metallic taste in their mouth;
both of these resolve quickly after the injection. Nausea with or without vomiting can also occur.
Certain patients may require a blood test to determine blood creatinine levels before receiving contrast material. In
many instances this can be performed in Radiology, but the process may slightly delay your scan.
Uncommon complications of contrast material injection include a temporary allergic-type reaction characterized by
itching and hives, or sneezing and swelling of the eyes and lips. You may receive Benadryl, an antihistamine, if the
radiologist believes your reaction warrants treatment. Another uncommon event is leakage of contrast material out of
the vein and into tissues near the injection site. This may cause localized pain and injury. The radiologist or nurse
may elevate the affected arm and place cold compresses about the injection site to help the swelling decline more
rapidly.
Very rare complications include, but are not limited to, shock, kidney failure, difficulty breathing, seizures, cardiac
arrest and death. We are prepared to treat such a reaction if it occurs, but in some instances we obtain assistance
from a hospital emergency care team.
Please note that even though your study may have been ordered by your doctor with contrast, the injection may be
withheld in some situations, such as an abnormal laboratory result or potential medication interaction.
PLEASE ANSWER THE FOLLOWING QUESTIONS (CONTINUES ON NEXT PAGE):
1. Have you received contrast material in the past?
If yes, did you have a reaction?
If you had a reaction, please describe:
□ Yes
□ Yes
□ No □ Unknown
□ No □ Unknown
2. Have you ever been pre-medicated before a contrast injection?
If yes, please describe:
□ Yes
□ No □ Unknown
3. Do you have a history of severe allergies or active asthma?
If yes, have you ever been intubated (had a breathing tube) for asthma?
If yes, please describe:
□ Yes
□ Yes
□ No □ Unknown
□ No □ Unknown
4. Do you have diabetes?
□ Yes □ No □ Unknown
If yes, please list medications you take for diabetes (insulin, Glucophage, metformin, etc.):
5. Do you have any of the following medical conditions (check all that apply)?
□ Poorly-controlled high blood pressure
□ Multiple myeloma / plasmacytoma
□ Heart disease
□ Myasthenia Gravis
□ Thyroid disease or thyroid cancer
□ Sickle cell anemia / sickle cell disease
□ Kidney disease or kidney transplant
□ Pheochromocytoma / ganglioneuroma /
neuroendocrine tumor
PLEASE CONTINUE ON NEXT PAGE →
6. Are you on dialysis?
□ Yes
□ No
□ Unknown
7. Do you have any other significant medical conditions?
If yes, please describe:
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Yes
□ No
FOR WOMEN
ONLY:
8. Is there any possibility that you may be pregnant?
9. Date of last menstruation:
/
/
10. Are you currently breast-feeding?
If there is any possibility that you are pregnant, certain CT scans and X-ray procedures
could theoretically cause harm to your unborn child.
FOR OUTPATIENTS
ONLY:
11. Have you had anything to eat or drink in the last two (2) hours?
□ Yes □ No
12. Please list any medications you currently take:
FOR ALL PATIENTS:
13. Do you wish to discuss contrast further with a Radiology nurse or physician?
□ Yes
□ No
When your question(s) about contrast have been answered, please acknowledge below:
“I have completely read and given the information required on this form. I fully understand its
contents, including possible risks and complications. I have been given an opportunity to ask
questions. All of my questions have been answered fully and satisfactorily.”
Signature: X
Printed Name:
Relationship to patient:
Date:
/
/
(e.g., self, parent/guardian, spouse, clinician, etc.)
Individual providing patient history, if different from above:
TO BE COMPLETED BY RADIOLOGY PERSONNEL:
Discussion/Notes:
Signature:
BUN/Creatinine:
Printed Name:
Estimated GFR:
Date:
/
/
Date of Lab Results:
/
/
/
PLEASE CONTINUE ON NEXT PAGE →