CT Cardiac/Coronary Angiogram Patient Questionnaire

Patient details

First Name *

Last Name *

Mobile number *

Date of your booking *

Which centre are you attending? *

Cardiac Medical History

1. Please tick any HEART surgeries that have been performed on you *

Stents in heart (upload any documents if available)Cardiac Bypass (upload any documents if available)Pacemaker (upload any documents if available)OtherNone

Other (please specify):

Please upload any heart surgery documents/reports here

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2. Have you had any of the following cardiac tests performed in the last 12 months? Tick all that apply, *

Stress test (upload any results if available)Echocardiogram (upload any results if available)Holter Monitor (upload any results if available)ECG (upload any results if available)UnsureNo

Please upload your cardiac test results here

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3. Do you have any allergies? *

No Yes (please list allergies)

Allergy

Medications

4. Did your doctor ask you to take any medication before your CT scan? *

No Yes (please provide medication details below and bring any available medication packaging in on the day)

Medication name

Dose/Strength (mg)

Time(s) taken (morning, noon, evening)

5. Are you on any regular medication currently? *

NoYes (please provide medication details below)

Medication Name

Dose/Strength (mg)

Time(s) taken (morning, noon, evening)

OR please upload a copy of your current medications

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Preparing for your test

Where you given preparation instructions at the time of your booking? (These include instructions on fasting, stopping medication etc.) *

No Yes

Having a driver to take you home after your appointment is strongly recommended. Will you have a driver on the day of your test? *

NoYes

Please arrive 1 hour prior to your appointment time, as there will be other medical and consent forms that you will need to complete.
You may also be given some medication in preparation for your cardiac scan, which will need time to take effect.

Referral Form

If you have not already done so, please upload your referral here

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