ESUR guidelines on Contrast Media

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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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D. Questionnaires