Scribd Logo
Upload

Welcome to Scribd!

  • 33 views

    Bone Scan Form

    Uploaded by

    BK
    This document appears to be a requisition form for nuclear medicine tests from a department of nuclear medicine. It requests information about the patient such as name, age, sex, and contact details as well as clinical details and the reason for referral. The form also provides general instructions for patients undergoing nuclear medicine tests, such as bringing previous records, complying with fasting instructions, and being available for the full duration of the testing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Bone Scan Form

    Uploaded by

    BK
    33 views2 pages
    This document appears to be a requisition form for nuclear medicine tests from a department of nuclear medicine. It requests information about the patient such as name, age, sex, and contact details as well as clinical details and the reason for referral. The form also provides general instructions for patients undergoing nuclear medicine tests, such as bringing previous records, complying with fasting instructions, and being available for the full duration of the testing.

    Original Description:

    mmmmmmmmmmmmmmmm

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document appears to be a requisition form for nuclear medicine tests from a department of nuclear medicine. It requests information about the patient such as name, age, sex, and contact details as well as clinical details and the reason for referral. The form also provides general instructions for patients undergoing nuclear medicine tests, such as bringing previous records, complying with fasting instructions, and being available for the full duration of the testing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    33 views2 pages

    Bone Scan Form

    Uploaded by

    BK
    This document appears to be a requisition form for nuclear medicine tests from a department of nuclear medicine. It requests information about the patient such as name, age, sex, and contact details as well as clinical details and the reason for referral. The form also provides general instructions for patients undergoing nuclear medicine tests, such as bringing previous records, complying with fasting instructions, and being available for the full duration of the testing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    a f e fafhrHT aHTT

    Department of Nuclear Medicine


    All dia Institute of edical Sciences, Bhopal

    REQUISITION FORMJ

    Date: UHID:
    Sex
    Name: Age:

    Address Phone Number:

    hical and other relevantfindings (To be filled by referring physician

    Clinical Indication (What specific information is required ?

    Consultant 1/C: Department:

    No. of previous study:


    If follow up, date and NM
    OPD/Ward:

    3. Endocrine
    2. Cardiovascular
    1. Skeletal Rest) Thyroid Scan
    Myocardial Perfusion Imaging (Stress
    +
    Whole Body bohe scan -131 Whole Body Scan
    Please specify the type of stress_
    Three Phase bone scan RAIU (lodine uptake)
    Parathyroid Scan (Sestamibi)
    Myocardial Perfusion Imaging (Rest only)
    MIBG Scan

    5. Genitourinary 6. Nervous system


    4. Gastrointestinal ECD/HMPAO Brain SPECT
    ODTPA/EC scan
    Gastric emptying
    ODMSA Scan Brain tumor Imaging
    G I Bleed scan
    M e c k e > ' s scan DRCG

    HIDA/Mebrofenin OTesticular scan


    7. Miscellaneous
    8. Radionuclide TheraPy 9. Other(Please specify
    Lung(V/Q) Scan O-131 therapyfor Thyrotoxicosis
    Lymphoscintigraphy
    O-131 therapy for Ca Thyroid (s30 mCi)
    Scintimammography
    Bone pain palliation (Sm-153)

    Name and signature of the referring physician:

    Designation:
    Date:

    Page 1 of 2
    patie
    T ATAATGeneral instructions for
    1. i T A TY T 3T
    2.

    3.

    4
    .

    6.

    8.
    9.

    1. Please come along with this requisition form on the day of appointment.
    schedule or need to change your
    2. lo Come on the given time. If you cannot come as per the given
    e
    dppointment, you must inform as soon as possible, so that another patient can be accommoddeu
    Please
    bring all your previous clinical records and investigation reports
    4, Female patients must declare their pregnancy status. Even suspicion of pregnancy mustbereve
    Breast feeding mothers should take instructions from the examining doctor for further feeding of the body.
    . ATter your clinical examination, you will be called for administrátion of a radiotracer. After that you have to wait till

    you are called for investigation.


    YOur waiting period to complete the entire investigation may be as long as 6 hours. So please bring food as required

    by you.
    8. Please do not leave the department until you are asked to do so. Sometimes the investigations may have to be
    repeated for satisfactory results.
    9. The radioisotope for your investigation comes from B.A.R.c. Mumbai. Sometimes due to unavoidable circumstances
    it may not come in time. In such a case you will be givena new date for the investigation.
    10. If any special preparation is needed for the test, it will be provided while giving appointment for the investigation.
    Kindly strictly comply to the instructions given, else your investigation can be postponed.
    11. The need to come fasting for the investigation will also be informed while giving appointment.

    a T Ü E aT FT/ Date and time of appointme

    Appointment given by:

    faT &Tt/AËr, af
    Special preparation/ Instructions, if any:

    Page 2 of 2

    You might also like