MILFORD HOSPITAL
C.T. SCAN
Acknowledgement of Understanding
NAME: _______________________________________________________________
DATE:
As part of your C.T. Scan you may receive an injection of a solution commonly known as x-ray “dye”
into a blood vessel. This is used for the purpose of showing body structures that do not show up on
regular x-ray. While considered safe and effective by the FDA and used for years for many x-ray
tests, although rare, can cause complications and therefore is not entirely without risk to you. Hives,
inflammation to the blood vessel, rare interference with breathing or circulation may occur. A fatal
allergic reaction (which can occur with almost any medication) is extremely rare. We do not feel the
risk is sufficient to alarm you; however, you must be made aware of the possibility before hand. We
must inform you that if you have an Advanced Directive or Limitation of Treatment Order, it will be
automatically suspended or modified during an invasive diagnostic, therapeutic, or operative
procedure in which acute cardiac or pulmonary arrest may result as a consequence of such a
procedure. A “Resume LOT Order” will be written post procedure.
Please answer all questions
YES
NO
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Pain? Where and how long?
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Any urinary retention and/or blood in urine
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Any nausea and/or vomiting
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Cough? Is it productive?
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Headaches or dizziness after trauma to your head
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Sinus congestion? Prior sinus surgery
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Visual impairment
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Hearing loss
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Trouble speaking
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Any recent numbness, weakness, or tingling in your arms or legs; If yes where:
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Have you ever had any form of cancer? If yes, where:
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Treatment for cancer:
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Have you ever had surgery? If yes when & what type?
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Have you had any barium exams or problems not listed above? If so, what?
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Have you had any change in bowel habits, diarrhea or constipation?
Please answer the following:
Yes
No
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Have you ever had x-ray dye before? If so, what type?
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Have you ever had a reaction to x-ray dye? If yes describe:
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Have you ever broken out in hives from any food or medications?
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Is there any chance of pregnancy? LMP:
Please check appropriate box:
Yes
No
Yes
No
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Allergies to food
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Allergies to Medications
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Allergies to shellfish
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Asthma
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Emphysema
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Sickle Cell
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Respiratory Problems
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Diabetes
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Kidney Problems
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Heart Problems
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Multiple Myeloma
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Nursing Mother
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Myasthenia Gravis
I have read the above information, understand the possible risk involved, and agree to have the injection of x-ray dye.
Sign:
Date:
Tech Initials:
Date: