Patient Information about IV Contrast Reaction
Patient Name _________________________________________ Date ___________________
Med. Rec. No. ___________________________
Study Performed__________________________ Location_____________________
(Circle and/or fill in the blanks with the appropriate information)
1. Have you ever experienced mild/moderate/severe reaction from the following contrast? If
so, please circle the contrast:
Non-Ionic Contrast Ionic Contrast Iodixanol
Oral Iodinated Contrast Gadolinium Barium
2. Describe your symptoms from the reaction:
Nausea/Vomiting________________ Cardiac _______________________
3. Describe how you were treated from the reaction::
Monitoring only: ____________________________________________________________
4. Describe any follow-up care:
5. Please tell your doctor that you have had a reaction to contrast. If you have a follow-up
appointment, please give this form to your doctor. If your reaction was mild, premedication
may be needed for future Radiology exams.
6. Watch for these signs and symptoms for the next 24 hours:
Shortness of breath/difficulty breathing/rapid breathing
Blood pressure changes either high or low
For emergencies, please go to the nearest emergency room or call 911.
7. If you have any questions or concerns, please call your doctor or call:
Radiology Department at (608) 263-9729, M-F, 8:00am to 8:00 pm. Please state your name
and the exam you had, and where the exam was performed so the receptionists can connect
you with the proper personnel.
After 8:00 pm, weekends, or holidays, please call (608) 262-0486. This is the hospital
paging operator. Ask for the Radiology Resident on call. Give the operator your name and
phone number with the area code. The doctor will call you back.
If you live outside the area, please call 1-800-323-8942.
Your health care team may have given you this information as part of your care. If so, please use it and call if you
have any questions. If this information was not given to you as part of your care, please check with your doctor. This
is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each
person’s health needs are different, you should talk with your doctor or others on your health care team when using
this information. If you have an emergency, please call 911. Copyright © 10/2016. University of Wisconsin Hospitals
and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#5483.