Download diagnostic imaging: ultrasound radiology bone mineral density

THIS DOCUMENT MUST BE COMPLETED BY A PHYSICIAN (must not be completed by patient)
DIAGNOSTIC IMAGING: ULTRASOUND
RADIOLOGY
BONE MINERAL DENSITY
Ordering Physician Name
OUTPATIENT SERVICES
(Please Print)
Name:
Ordering Physician Signature
QHC-BG
265 Dundas St. E
Belleville, ON
K8N 5A9
QHC-TM
242 King St
Trenton, ON
K8V 5S6
QHC-PECM
403 Main St. E
Picton, ON
K0K 2T0
QHC-NH
1-H Manor Lane
Bancroft, ON
K0L 1C0
DOB:
HCN:
Phone #:
Address:
Copy to:
Pregnant: Yes  No
LMP:
 ER patient in EMERG
 ER patient sent Home

Routine

Stat

Urgent
PLEASE BRING THIS REQUISITION AND YOUR HEALTHCARD
PATIENTS PRESENTING UNSIGNED/INCOMPLETE REQUISITIONS WILL BE RE-BOOKED
APPOINTMENTS MUST BE MADE THROUGH CENTRAL BOOKING AT 613-969-7400 EXT. 2494 OR EXT. 2949
IF CALLING FROM BANCROFT AREA CALL 613-332-2825 EXT. 2494 OR EXT. 2949
Clinical Indication/History:
XRAY
ULTRASOUND
Appointment Date & Time:
QHC Site:  BG  TM
 PECM  NH
Lower Extremities
Chest
Upper Extremities
 Pelvis
 Chest
 A.C. Joints
L S.I. Joints
R
R
 Sternum
L Clavicle
L Hips
R
R
L Shoulder
 Thoracic Inlet
L Femur
R
L Ribs
R
R
L Scapula
R
L Knee
R
L SC Joints
R
L Humerus
L Tib & Fib
R
R
L Elbow
Appointment Date & Time:
QHC Site:  BG  TM
 PECM  NH
 Carotids
 (PVD) Peripheral arterial area of interest: _____________
 (DVT) Peripheral venous area of interest: ____________
 Chest
 Wall Mass
 Pleural Effusion
 Abdomen
 Kidney, Ureters & Bladder (KUB)
Pelvis (Female)

 Transvaginal
 Pelvis (Male)
 TRUS BX: Must be referred by a Urologist
 Testes/Scrotum
 Thyroid
 Obstetrical
 ≤ 15 wks
 >16 wks
 Biophysical Profile
 Medically Warranted
 Musculoskeletal
 Shoulder
 Superficial Mass
L Ankle
R
L Foot
L Os Calcis
Toes
L
12345
G.I. Tract
 Ba Swallow
R
R
Abdomen
 Plain film (KUB)
 Acute (3 Views)
L
Forearm
R
L
L
R
R
Head and Neck
 Skull

Wrist
Hand
Fingers
T2345
Spine
Cervical
 Upper G.I. Series

Sinuses

Thoracic
 Small Bowel


Lumbar
 Barium Enema

Soft tissue
Neck
Facial bones

Scoliosis

Orbits

R
 Mandible
 Other:
___________________________________
___________________________________
___________________________________
L



Sacrum & Coccyx
Skeletal Survey
Bone Age
Arthritic
Metastatic
BONE MINERAL DENSITY
Appointment Date & Time:
QHC Site:  BG
 Routine
 High Risk
QHC # 408
Rev: May 2011
R
 TM
Height:
Weight:
 Area of Interest: __________________

Other:
TECHNOLOGIST NOTES:
THIS DOCUMENT MUST BE COMPLETED BY A PHYSICIAN (must not be completed by patient)
Bring your requisition & Health Card to your appointment.
Arrive 30 minutes prior to appointment for registration.
If unable to keep appointment, please give 24 hours notification.
All QHC hospitals are designated as a reduced scent environment.
We do not provide child care, please leave young children at home
DIAGNOSTIC IMAGING INSTRUCTION SHEET
 DIABETICS: Please inform us at the time of booking so that an early appointment can be arranged. If having
an injection of a contrast medium (x-ray dye), Metformin HCL (Glucophage) must be stopped on the day of the
exam, and for an additional 48 hours after contrast injection. Normal renal function must be confirmed prior to
restarting this medication. If urine output decreases, contact your doctor.
 FEMALE PATIENTS: If there is a possibility that you are Pregnant, please inform your doctor and the
technologist. If possible, book your appointment within ten (10) days following the onset of menstruation, since
the risk of pregnancy is small during this period.
X-RAY
 UPPER GI SERIES, SMALL BOWEL STUDIES, and ESOPHAGUS: Do not eat or drink after midnight on the
night before your test. Bring your morning oral medications with you and take them after your test. Do not
smoke or chew gum on the day of the test. Expect small bowel studies to take a minimum of two hours.
 BARIUM ENEMA, IVP (INTRAVENOUS PYELOGRAM): Purchase one (1) box of Pico-Salax and four (4)
Bisacodyl tablets from a pharmacy. The day before your test, remain on a clear fluid diet (clear “pulp-free” fruit
juice, plain jello, clear soup such as consommé, bouillon, tea, coffee…no milk). At 1:00 p.m., take 4 Bisacodyl
tablets. Drink lots of clear fluids. At about 4:00 p.m. take the first packet of Pico-Salax (prepare as the
package indicates). Drink a large glass of water every hour. At about 8:00 p.m. take the second packet of
Pico-Salax. Do not eat or drink after midnight.
BONE MINERAL DENSITY
 Do not take any calcium supplements day of exam. Appointment should not be booked within 2 weeks of
having any X-ray exams involving contrast agents or having had a nuclear medicine appointment.
Dress comfortably, wear loose fitting clothes
ULTRASOUND
 ABDOMINAL ULTRASOUND: Do not eat or drink anything for 6 hours prior to the examination. Do not chew
gum the day of your test.
 ABDOMINAL/PELVIC ULTRASOUND: Do not eat for 6 hours prior to the examination. . Do not chew gum the
day of your test. Finish drinking 1 Litre of fluid 1 hour before your examination time. Do not empty your bladder.
 PELVIC ULTRASOUND: Finish drinking 1 Litre of clear fluid 1 hour before examination time. Do not empty




your bladder. A Transvaginal study may also be requested which involves the insertion of the ultrasound probe
into the vagina for optimal visualization of the pelvic structures. The bladder will be emptied for this portion of
the examination.
OBSTETRICAL (PREGNANCY) ULTRASOUND: Before 20 weeks (4 ½ months)—follow the instructions for
the Pelvic Ultrasound above. After 20 weeks (4 ½ months)—Do not drink fluids, but do not empty your bladder
1 hour before examination time.
KIDNEY/BLADDER ULTRASOUND: Finish drinking 1 Litre of clear fluid 1 hour before examination time. Do
not empty your bladder.
TRUS BIOPSY: Stop taking aspirin 1 week prior to procedure. Discuss stopping any other blood thinners with
your physician. An antibiotic must be prescribed prior to your procedure.
LIVER BIOPSY: Light breakfast morning of procedure. Discontinue taking aspirin &/or arthritic antiinflammatory medications 4 to 5 days prior to the procedure (Tylenol is acceptable) Discuss stopping any other
blood thinners with your physician.