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D. Questionnaires

to be completed by clinicians referring patients for examinations using iodine- or gadolinium-based contrast media.

 

Questionnaire for iodine-based contrast media administration to be completed by the referring clinician.
   Yes No
1. History of moderate or severe reaction to an iodine-based contrast medium         
2. History of atopy requiring treatment    
3. History of unstable asthma    
4. Hyperthyroidism    
5. Heart failure    
6. Diabetes mellitus    
7. History of renal disease    
8. Previous renal surgery    
9. History of proteinuria    
10. Hypertension    
11. Gout    
12.

Most recent measurement of serum creatinine

• Value.............................................
• Date ..............................................

 

 

13.

Is the patient currently taking any of the following drugs

 
  • Metformin

 

 
 
  • Interleukin 2

 

 
 
  • NSAIDs

 

 
 
  • Aminoglycosides

 

 
 
  • ß-blockers

 

 

 

Completed by ______________________________________ Date ________________________

 

 

  

Questionnaire for gadolinium-based contrast media administration to be completed by the referring clinician.

  Yes No
1. History of moderate or severe reaction to a gadolinium-based contrast medium            
2. History of atopy requiring treatment    
3. History of unstable asthma     
4. Has the patient end-stage renal failure (eGFR < 30 ml/min/1.73m2) or is the patient on dialysis    
5. Has the patient reduced renal function* (eGFR between 30 and 60 ml/min/1.73 m2)          

* Only if high-risk agents are used.

 

Completed by ______________________________________ Date ________________________

 

 

 

 

 

 

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