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Interventional Radiology

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					                                 Interventional Radiology
                   Patient Screening             FAX to IR 5-0130
Name: ________________________              Location: ____________   Phone: ______

Medical Record No.: ___________              DOB: _______________

Procedure:




Referring MD: _________________              Phone/Pager: ________________________

Date: _________________________              Time: ______________________________

Brief History/ Co-morbid conditions:




IV Access:                                          Yes         No

NPO Status (6 hours):                               Yes         No

Code Status:                                        Full        Other

Able to Consent:                                    Yes         No
       If not, contact:

Able to lie flat:                                   Yes         No

Able to follow commands:                            Yes         No

Medications
      Anticoagulants/ASA:                           Yes         No
      Insulin:                                      Yes         No
      May be Sedated:                               Yes         No

Allergies:                                          Yes         No

Labs and Date:
      BUN __________             Creatinine _____________

            INR ___________      PT ________ PTT ______

            Platelets ________
            Other

Prior Imaging:                                      Yes         No
       Location: _____________________

Radiology Resident: __________________
FFI/7-004

				
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posted:6/29/2012
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Lingjuan Ma Lingjuan Ma
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