CT Cardiac/Coronary Angiogram Consent and Questionnaire

Patient details

First Name *

Last Name *

Mobile number

Date of your booking

Which centre are you attending?

Pre-medication Consent

Your doctor has requested us to perform a CT scan to investigate your heart and its blood vessels. To achieve clear and still images, the heart ideally should be beating at a slow and steady rate (<60bpm). A normal heart rate can vary between 55-100 bpm, so in order to achieve a reliable heart rate of <60 bpm, medication is normally given before the scan to lower the heart rate to the target range. The medications commonly given are known as beta blockers (Metoprolol) and HCN channel blockers (Ivabradine).

Metoprolol and/or Ivabradine: The medication is usually given in a tablet form, which normally takes 1 - 1.5 hrs to take effect. Occasionally, an injection form of the medication is also given. The medication will lower your heart rate as well as your blood pressure temporarily. The effects of the medication will last for a few hours, where it will slowly wear off and you should return to your normal heart rate and blood pressure.

It is common to experience some mild dizziness, light-headedness and tiredness after you are given the medication, especially if it is your first time using it. Therefore, it is important that you have organised a driver to take you home after the examination, as it may not be safe to drive or operate machinery for a few hours.

The amount of medication you will be given will depend on your initial heart rate, and your medical history factors. If you have a history of moderate to severe asthma or obstructive lung conditions, you will most likely be given Ivabradine only. Metoprolol can increase the chances and severity of an asthma attack.

Nitrolingual Spray: A medication called Nitrolingual Spray (GTN) will also be sprayed under your tongue just before the scan. This medication will open up the blood vessels of the heart for better diagnosis. The spray can give you a headache afterwards, but the effects of the spray only last for approx 20-30 mins before wearing off. Your blood pressure may decrease temporarily after having the spray.

You will be closely monitored during the exam. Adverse or allergic reactions are very rare, but can occur. These can include very low blood pressure, low heart rate, severe dizziness and fatigue, fainting and loss of consciousness, breathing difficulties, asthma, shock, and circulatory disturbance. Signs of an allergic reaction can be sneezing, itchy rash/hives, tingling of the lips, swelling of the face, lips, tongue or throat.

I have read and understood the information above and hereby consent to the administration of cardiac premedication. *

Clear

Medical History

Other (please specify) *

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 or similar device (upload any documents if available)Other None

Please upload any heart surgery documents/reports here

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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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Do you have any allergies?

No Yes (please list allergies below)

Allergy (mention any history of anaphylaxis) *

Do you ever have episodes of low blood pressure? *

NoYes

Details (Frequency)

Have you had any recent stroke or brain bleeds? *

NoYes

Details

Do you have severe peripheral artery disease? *

NoYes

Details

Do you have severe kidney impairment? *

NoYes

Details

Do you have severe liver impairment? *

NoYes

Details

Do you have asthma? *

NoYes

Do you take regular asthma medication?

No Yes

Medication name

Frequency

Please tick any other LUNG conditions that apply to you *

EmphysemaCOPD/COADOtherNone

Other (please specify):

Medications

Were you given medication from your doctor to take in preparation for the test? *

NoYes (please provide medication details below and bring any available medication packaging in on the day)

Medication name *

Dose/Strength (mg) *

Frequency (how many doses) *

Time of last dose *

Do you currently take heart medication? *

Heart Medication details *

Do you currently take blood pressure medication? *

No Yes

Medication Name *

Dose/Strength (mg)

Frequency (morning, night etc.)

Time of Last Dose (taken prior to your appointment) *

Do you take diuretics or "fluid tablets"? *

No Yes

Medication Details *

Reason for taking this medication *

Do you take Viagra, Levitra, Cialis, or similar medication? *

NoYes

Medication Details

Do you take Cyclosporin, Ketoconazole, or Gestodene medication? *

NoYes

Medication Details

Are you on any antibiotics, anti-fungal or anti-viral medication? *

NoYes

Medication Details

Are you on any SSRIs, e.g. Zoloft? *

NoYes

Medication Details

Are you on any other prescription medication not mentioned above? *

NoYes

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

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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