3676 Parker Boulevard ¨ Suite 165 ¨ Pueblo, Colorado 81008

                                                                       Phone 595-7600 ¨ Fax 595-7661

                                                              PATIENT SCAN INFORMATION SHEET

                                                    (Please print this sheet and bring it with you)

PATIENT NAME______________________________________________________  DATE______________________

ARE YOU A DIABETIC?___________   IF YES, YOUR BLOOD SUGAR NEEDS TO BE BELOW 200.

ARE YOU CLAUSTROPHOBIC?__________  IF YES, HAVE THE DOCTOR  PRESCRIBE A SEDATIVE FOR THE EXAM.

HAVE YOU HAD PREVIOUS CT'S, MRI'S OR PET SCANS?

                ST. THOMAS MOORE____________

                ST. MARY-CORWIN______________

                PARKVIEW____________________

                OTHER________________________

IF FILMS WERE NOT DONE AT PARKVIEW MEDICAL CENTER OR PARK WEST IMAGING, WOULD YOU PLEASE BRING THE FILMS WITH YOU.

DO YOUR DOCTORS HAVE COPIES OF THE FILMS?___________

DOCTORS THAT NEED A COPY OF THE EXAM RESULTS:  _______________________________________________________________

ARE YOU RECEIVING CHEMOTHERAPY?__________   WHEN WAS YOUR LAST TREATMENT?______________________

OTHER__________________________________________________________________________________________________________

                                                        INSTRUCTIONS FOR PATIENT PREPARATION

v     PLEASE ARRIVE AT PARK WEST IMAGING 30 MINUTES PRIOR TO YOUR SCHEDULED EXAM EARLY TO COMPLETE PAPERWORK

v     EXAM TAKES APPROXIMATELY 90 MINUTES.  YOU WILL BE INJECTED WITH AN ISOTOPE BOUND INTO A SUGAR SOLUTION.  YOU WILL THEN REST FOR 45 MINUTES.  THE SCAN WILL THEN TAKE ABOUT 45 MINUTES.

v     NOTHING BY MOUTH AFTER MIDNIGHT EXCEPT  WATER, FOR AT LEAST 5 HOURS PRIOR TO THE EXAM. (EAT LIGHT)

v     YOU MAY TAKE ALL OF YOUR MEDICATIONS IF YOU CAN TAKE THEM ON AN EMPTY STOMACH.  IF YOU NEED TO TAKE THEM WITH FOOD GET UP EARLY, AT LEAST 3 HOURS BEFORE EXAM . TAKE  MEDICATIONS WITH CRACKERS OR A SMALL PIECE OF BREAD.

v     IF YOU ARE A DIABETIC,  YOUR BLOOD SUGAR NEEDS TO BE LESS THAN 200.  PLEASE BRING YOUR GLUCOSE MONITOR WITH YOU TO THE TEST.

v     NO STRENUOUS EXERCISE THE NIGHT BEFORE THE EXAM.

v     WEAR LOOSE CLOTHING WITH NO SNAPS OR ZIPPERS.  IT IS OKAY TO WEAR YOUR BRA.

v     INTRAVENOUS FLUIDS CONTAINING GLUCOSE OR TPN SOLUTIONS MUST BE DISCONTINUED 6 HOURS PRIOR TO EXAM.

v     IF YOU ARE UNABLE TO ATTEND APPOINTMENT, YOU MUST GIVE US 24 HOURS NOTICE OR YOU WILL BE CHARGED $529.00 FOR COST OF ISOTOPE.

                                                                                                       Park West Imaging Home

                       IF YOU HAVE ANY QUESTIONS, PLEASE CALL PARK WEST IMAGING AT 719-595-7600

                                                                                 Copyright 2007, CS Higbee Electronics