Cullman Primary Care, P.C.
Diagnostic Center
Tuesday, February 09, 2016
Name_____________________________
DOB _________________
Are you allergies to iodine (CT or IV X-ray contrast)? ________________________
It is OK to be allergic to seafood, shellfish. In the ACR (American College of Radiology) contrast
manual, there is no evidence to support a contraindication to receiving iodine contrast.
If so, what happened and when? _______________________________________
Fainting is a reaction, but typically not an allergic reaction.
Do you have any kidney function problems? _____________________________
Are you taking Glucophage? _______ If so, when was your last dose? ______________ You
should be off Glucophage for 2 days before receiving IV iodine contrast.
FYI: Glucophage (metformin) is an oral diabetic medication. You should not take it for 2 days
prior to this exam. It rarely causes a problem even if you are still taking it. The problem occurs if
you develop kidney failure from the iodine contrast that we give you. If you have metformin in
your system and you develop kidney failure from the contrast, you can develop a metabolic
acidiosis.
Patient signature: ___________________________
FYI kidney function:
Worsening kidney function caused the glomerular filtration rate (GFR) to decrease. This is
determined from a creatinine level. The normal level is around 1.0 mg/dL. Our lab uses the
method that includes creatinine level, age, race, gender.
Chronic kidney disease is GFR < 60 for > 3 months
Normal
Mild kidney damage
Moderate
Severe
Kidney failure
> 90 ml/min/1.73 m2.
60-89
30-59
15-29
< 15 (or dialysis)