REENING FORM ADDRESSOGRAPH Before beginning your study, it is necessary that you answer the following questions: COMMENTS / DESCRIBE: Have you ever had contrast material (dye) for a kidney x-ray, CT, MRI or other imaging test/study? YES NO If YES, did you have any discomfort, ill effects, or allergic reaction? If Yes, Describe: YES NO Do you have asthma or severe allergies? If Yes, Describe: YES NO Do you have diabetes? YES NO Do you take (, , Gluc.
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How to fill out the UVA Downtime IV Contrast (DYE) Screening Form online
Filling out the UVA Downtime IV Contrast (DYE) Screening Form is an essential step in ensuring your safety during imaging procedures involving contrast material. This guide will walk you through the process step-by-step, making it easy to complete your form online.
Follow the steps to successfully fill out the form.
- Use the ‘Get Form’ button to access the UVA Downtime IV Contrast (DYE) Screening Form and open it for completion.
- Begin by entering your personal information, including your name and medical record number (MR #) at the top of the form.
- Answer the questions regarding your previous experiences with contrast material. Make sure to clearly indicate whether you have ever had contrast dye for imaging tests, and if so, whether you experienced any discomfort or allergic reactions.
- Proceed to the health-related questions. You will indicate 'yes' or 'no' regarding conditions such as asthma, allergies, diabetes, kidney disease, and other specified medical histories. Provide descriptions where applicable.
- If you are a patient who is pregnant or breastfeeding, please answer the corresponding question accurately.
- Ensure that you sign and date the form where indicated to verify the information provided.
- Once all sections are completed, you will have the option to save changes, download, print, or share the form, ensuring that you have a copy for your records.
Complete your UVA Downtime IV Contrast (DYE) Screening Form online today to help ensure your safety during imaging procedures.
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