Get Ct Scan Screening Questionnaire - Radiology Ucla

The CT scan screening questionnaire is critical for ensuring patient safety and preparation prior to undergoing a computed tomography scan. This guide provides clear instructions for completing the form online, helping users navigate each section effectively.

Follow the steps to complete the questionnaire with ease.

1. Press the ‘Get Form’ button to access the CT scan screening questionnaire. This will allow you to open the form in your preferred online editor.
2. Begin by filling in your Medical Record Number (MRN) and your full name at the top of the form.
3. For the height and weight fields, accurately input your height in feet and inches, followed by your weight in pounds.
4. Proceed to the first section titled 'CT Non Contrast' where you will address whether the safety screening is being waived by the medical doctor due to urgency. Select 'Yes', 'No', or 'Unknown' as applicable.
5. If you selected 'Yes', provide the MD’s name and pager ID in the designated sections.
6. Next, indicate if you weigh more than 440 lbs or if there is a possibility of pregnancy. If pregnant, additional information about gestational weeks is required.
7. Move on to the section for 'CT with Contrast and/or Interventional CT'. Here, respond to whether you have any allergies to iodine or complications related to injected contrast. If applicable, describe any complications.
8. Answer if you are on dialysis and provide the date of your next appointment, and detail any central venous catheters or lines you may have.
9. Indicate if you have asthma or use an inhaler, listing any diabetes medications you take. If you take , mention those drugs as instructed.
10. Continue answering questions about kidney history, solid organ transplant evaluations, high blood pressure, diseases, and any recent chemotherapy.
11. In the 'Cardiac/Coronary CT' section, indicate if you have used beta blockers or specific medications for blood flow and their impact.
12. At the bottom of the form, the individual completing it should print their name and provide a signature, as well as the date and time the questionnaire was filled out.
13. If someone else completed the form on behalf of the patient, they should specify their relationship to the patient and provide their own signature and ID.
14. Finally, ensure all information is accurate, and save your changes. You may then download, print, or share the completed form as required.

Complete your CT scan screening questionnaire online today for a smooth and efficient process.