Download form 201 - Basha Open MRI

PLEASE CHECK BOXES BELOW FOR EXAM & LOCATION
Basha Diagnostics, P.C.
Open MRI Available
ROYAL OAK MED. CLINIC STERLING HEIGHTS CLINIC
DEARBORN (ROEMER) CLINIC
DEARBORN CLINIC
(248) 435-8066
(586) 566-8680
(313) 584-0768 • FAX (313) 945-9339 (313) 945-5939 • FAX(313) 945-5932
These are general instructions. Any questions or problems with preparation, please contact Dr. Basha and/or your physician.
Time
Patient’s Name
D of B
Appointment Date
History & Clinical Diagnosis:
Date
Physician’s Signature
MRI
Case #
Head, Chest, Complete Spine, Pelvic and Abdominal, Upper and Lower Extremities. . .Other
MRA c Renal Arteries c Aorta c Lower Extremities c MRV-Lower Extremities
CT SCAN/CTA Head, Chest, Complete Spine, Pelvic and Abdominal, Upper and Lower Extremities. . .Other
Provisional Diagnosis
History and Positive Findings
History of allergies or any contraindications using contrast medias:
BONE DENSITY
X-RAY REQUEST
N
O
T
E
1.
2.
3.
Diabetic patients with severely debilitating diseases and patients with special problems such as colostomy, please contact your physician or Dr. Basha for special
instructions.
Patients with any and all allergic conditions, including but not limited to asthma, hay fever and allergies to foods, medications, dust, etc. inform Dr. Basha or
technologist when scheduling appointment for IVP, etc.
Every woman who is possibly pregnant requesting X-rays, please speak to Dr. Basha prior to test.
BARIUM ENEMA
FL.A.B.D.
BE WITH AIR
FL.A.B.D.
2 days prior to examination, diet of clear
l i q u i d s , c r a c k e r s , j e l l o , r i c e , p a s ta .
1 day prior to examination, drink ONLY clear
liquids, see**. Take 10 oz. Citrate of Magnesia,
and 3 Dulcolax tablets at 3:00 p.m. Drink at
least 24 oz. of water in afternoon.
INTRAVENOUS UROGRAM & LAM
UPPER GASTROINTESTINAL SERIES
CYSTOGRAM
AND SMALL BOWEL SERIES & A.B.D.
VOIDING CYSTOURETHROGRAM & A.B.D.
1. At 4p.m. of the preceding day, take a total of
4 Dulcolax tablets; (take 2 every 15 mins.)
2. Eat Nothing after midnight preceding the
appointment. No fluids 3 hrs. prior to test.
On the morning of the examination, take a tap
water enema using at least 1 pint of water. If it
is not clear, repeat it with a second enema. DO
NOT exceed 2 enemas.
**No vegetables, fruit, or dairy products.
MAMMOGRAPHY
After bathing, on the day of exam, DO NOT use
talcum powders, perfumes, lotions, antiperspirants,
deodorants or sprays.
EEG & EMG REQUEST
ELECTROENCEPHALOGRAPHY
EEG w/EVOKED POTENTIAL
ESOPHAGRAM
DO NOT EAT, DRINK, CHEW GUM, OR SMOKE
AFTER MIDNIGHT UNTIL EXAM COMPLETED.
After exam is completed, take 2 oz. of Milk of
Magnesia, drink water, and resume normal diet.
CARDIOLOGY/VASCULAR REQUEST
24 HOUR EEG
AUDIO
VISUAL
Wash hair prior to test.
DO NOT use cream rinse, gel, mousse, hair spray, etc.
Eat one good meal one hour prior to test.
ECHOCARDIOGRAM
COMPLETE
STRESS TEST
E.K.G.
HOLTER (24 HOURS)
CARTOID DOPPLER
(Waveforms)
(B-Mode)
ARTERIAL DOPPLER
VENOUS DOPPLER
Upper Extremity
Lower Extremity
ULTRASOUND REQUEST
Abdominal Study
___GB
___Pancreas
___Liver
Thyroid
Breast
Kidneys
Testicles
Soft Tissue
Mass
Abdominal Aorta
Other ________________________
Pelvis
Transvaginal
Transrectal
(Prostrate)
OB-Pregnancy
ULTRASOUND PREPARATION
ABDOMINAL - DO NOT eat or drink (no gum chewing) after midnight
prior to your examination. Appointments after 12 noon, do not eat or
drink anything 4 hours prior to your examination. You may drink any
liquids except for dairy products, and eat dry toast in the early morning.
Avoid fatty foods. Medications are permissable and a small amount of
water, unless indicated otherwise.
GALLBLADDER - On the evening of the day before your examination, eat a light supper of
lean meat, vegetables, fruit or fruit juice, toast with jelly, coffee, or tea. Avoid fatty or fried
foods and pastries. DO NOT eat or drink (no gum chewing) after the evening meal.
Medicaions with a small amount of water are permissable.
KIDNEY - Drink one 16 oz. glass of water before your examination.
PELVIS/PROSTRATE - Drink three to four 16 oz. glasses of water one hour prior to
examination. DO NOT URINATE.
OBSTETRICAL - If under 4 months pregnant - follow same instructions as PELVIS. If over 4
months pregnant - drink two 16 oz. glasses of water one hour prior to examination. DO NOT
URINATE.
NO PREPARATION IS REQUIRED FOR THE FOLLOWING EXAMINATIONS:
Breast, extremities, testicles, or soft tissue masses.
NUCLEAR REQUEST
NOTE: The materials used for these studies are expensive and short lived. Therefore, it is important that you keep this appointment. Any cancellation must be called in to us at least 24
hours prior to appointment.
PREPARATION FOR HEPATOBILIARY, THALLIUM STUDIES:
Nothing to eat or drink for 6 hours prior to examination.
THYROID:
BRAIN: (no preparation)
KIDNEY: (no preparation)
Thyroid profile (2 & 24 hr. uptake, scan)
Complete - Brain study (flow & scan)
Renal blood flow and scan
Thyroid scan (rapid evaluation with technetium)
ABDOMEN:
SOFT TISSUE: (no preparation)
Speak to nuclear technician regarding
Gallium Study
Liver & spleen (flow & scan)
medication changes for test
LUNG: (no preparation)
Hepatobiliary (Gallbladder)
BONE: (no preparation)
Complete lung study (ventilation and perfusion)
HEART:
Bone scan - Total Body
Perfusion only
Resting Thallium
Limited area
Ventilation only
Stress Thallium
Specify __________________________
Form 201
e.
n Av
Hayes
Schoenherr
Van Dyke
I-696
Royal Oak Clinic
ld
4045 W. 13 Mile Rd.
Royal Oak, MI 48073
(248) 435-8066 • Fax (248) 435-8099
Southfield
N
10 Mile
11 Mile
12 Mile
13 Mile
14 Mile
15 Mile
13753 19 Mile Rd.
Sterling Heights, NI 48313
(586) 566-8680 • Fax(586) 566-8730
Coolidge
Lapham
Greenfield Rd.
4407 Roemer
Dearborn, MI 48126
(313) 584-0769
(313) 584-0768
Fax (313) 945-9339
Romeo Plank
Sterling Heights Clinic
fie
Green
MRI ONLY
Dearborn Clinic
Schaefer Rd.
Basha
Diagnostics
ss
16 Mile
Ca
ks
4700 Greenfield Rd.
Suite Lower Level
Dearborn, MI 48126
(313) 945-5835
(313) 945-5939
(313) 945-9119
Fax (313) 945-5932
N
Michigan Ave.
Pontiac, GM,
Buick Dealer
Ford Rd.
N
17 Mile
19 Mile
d
ar
Dearborn Clinic
iga
Mich
30701 Woodward Avenue, Suite LL
Royal Oak, MI 48073-0988
(248) 288-1600 • FAX (248) 288-2171
Greenfield
M-59
dw
N
ld
Hubbard Dr.
Coolidge
Ford Rd.
I-696
ks
Medical Records &
Administrative Office
10 Mile
fie
Green
11 Mile
d
ar
N
Southfield
dw
12 Mile
o
W
13 Mile
14 Mile
15 Mile
I-75
Southfield Fwy. (M-39)
M-53
ica
Ut
oo
W
Charles
C ro o
Roemer
C ro o
Garfield
BASHA DIAGNOSTICS, P.C.
I-75