Diagnostic Imaging Associates

Coronary CT Angiography

Part I: To be completed by scheduling personnel

Patient First Name: Middle: Last:
Date of Scheduled CTA: xx/xx/xxxx

Are you a Nurse, PA or Physician? yes no
Is the Patient currently taking a Beta-Blocker,
Amiodarone, Verapmil, or Diltiazem? yes no
Does the patient have any known
contraindications to taking Beta Blocker? yes no
Asthma emphysema or COPD yes no
Active congestive heart failure – aka “wet lungs” yes no
Allergy to Metoprolol or Beta-Blockers yes no
Second or third-degree heart block yes no
Severe sinus bradycardia (heart rate <50) yes no

Note: If patient answers “YES” to any of the above, the study cannot be scheduled until the ordering physician discusses it further with a DIA radiologist.

Does the patient have history of previous cardiac surgery? yes no
If yes, where?
Is the patient allergic to IV contrast? yes no
Is the patient diabetic? yes no
If yes, does the patient take Metformin (Glucophage)? yes no
Does the patient have renal insufficiency? yes no
What was the patient’s last BUN or Creatinine?

Note: If the person calling to schedule the CT is not a Nurse, PA, or Physician, the DIA Scheduling Personnel may need to ask for a health care professional to answer the above questions.

If the patient is not on a Beta-Blocker, Verapamil, Diltiazem or Amiodarone and there are no contraindications to taking a beta blocker, arrange for the patient to receive Metoprolol orally one hour prior to the test (Patient should arrive one hour early for study and take after arriving at DIA office). The medication can be obtained from the ordering physician.

Part II: To be completed by Technologist (at visit)

Part III: Patient History Form

First Name: Middle: Last:
Date: xx/xx/xxxx
Height: Weight: lbs. Sex:
Birthdate: xx/xx/xxxx Age:
Address:
City, State, Zip:
Phone Number: (###) - ### ####
Email Address:

Family Doctor:
Phone: (###) - ### ####

Personal Medical History

Possibility of being pregnant yes no
Last Menstruation xx/xx/xxxx

Stroke or Mini-Stroke (TIA) yes no
Heart Disease yes no
Atrial Fibrillation yes no
Other Vascular Disease yes no
Chest Pain yes no
Persistent Cough yes no
High Blood Pressure yes no
High Cholesterol yes no
History of Alcholism yes no

Smoker yes no
#packs a day: # of years:

Cancer yes no
Type:

Diabetes: yes no
Osteoporosis: yes no

Surgery: yes no
Type and date of surgery:
Type and date of surgery:

Previous Heart Screening Test yes no
When: Where:

Family Medical History

Stroke or Mini-Stroke (TIA) yes no
Heart Disease yes no

Cancer yes no
Type:

Diabetes: yes no
Osteoporosis: yes no

Aneurysm: yes no
Where?

Gangrene yes no

Father:
Age
Deceased, age Cause of Death

Mother:
Age
Deceased, age Cause of Death

List current medications: