Contrast Media Safety Assessment Form
Complete this form to help screen for factors that may affect the safety of a contrast media imaging procedure.
Patient Identification and Imaging Context
Patient full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred contact method
*
Please Select
Phone
Email
Text message
Other
Type of imaging exam
*
Date of imaging exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contrast Safety Screening
Prior reaction to contrast media
*
No known prior exposure
No reaction
Mild reaction (e.g., nausea, flushing, itching)
Moderate reaction (e.g., hives, wheezing, swelling)
Severe reaction (e.g., breathing difficulty, anaphylaxis)
Unsure
Other
Known allergies or asthma
*
No known allergies or asthma
Yes, allergies
Yes, asthma
Yes, both allergies and asthma
Other
Kidney disease or reduced kidney function
*
No known kidney disease
History of kidney disease
Reduced kidney function
On dialysis
Unsure
Other
Diabetes or metformin use
*
No diabetes and not taking metformin
Diabetes, not taking metformin
Taking metformin
Diabetes and taking metformin
Unsure
Other
Pregnancy or breastfeeding status
Not applicable
Not pregnant and not breastfeeding
Pregnant
Breastfeeding
Unsure
Other
Assessment Summary and Acknowledgment
Clinician Review / Readiness for Contrast Media
*
Cleared for contrast
Proceed with precautions
Delay pending further review
Not ready for contrast
Submit
Should be Empty: