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Northern Hospital Epping Nuclear Medicine Department P: (03) 8405 9600 l E: niv.reception@niv.org.auMyocardial Perfusion Scan Request FormFull Name:Appointment Date & Time (NIV NIV Use Only): OnlyDOB:Sex:Phone/Mobile:Interpreter
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How to fill out myocardial perfusion scan request
How to fill out myocardial perfusion scan request
01
Start by gathering the patient's personal information, including name, age, gender, and contact details.
02
Include the patient's medical history, particularly any history of heart disease, risk factors, and symptoms.
03
Specify the reason for the myocardial perfusion scan, such as evaluating chest pain, assessing heart function, or pre-operative assessment.
04
Indicate any previous heart tests and their results, including echocardiograms, stress tests, or previous scans.
05
Provide current medications the patient is taking, especially any that may affect heart function or blood flow.
06
Ensure to select the correct type of scan required, whether it's a rest scan, stress scan, or both.
07
Sign and date the request form and include your professional credentials.
Who needs myocardial perfusion scan request?
01
Patients experiencing chest pain or discomfort.
02
Individuals with known heart disease or those at high risk for coronary artery disease.
03
Patients undergoing evaluation for heart conditions before surgery.
04
Individuals needing assessment of heart function after a heart attack.
05
Patients with abnormal results from other heart tests.
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What is myocardial perfusion scan request?
A myocardial perfusion scan request is a medical document used to authorize a myocardial perfusion imaging test, which evaluates blood flow to the heart muscle and helps in diagnosing coronary artery disease.
Who is required to file myocardial perfusion scan request?
A healthcare provider, typically a physician or a cardiologist, is required to file the myocardial perfusion scan request on behalf of the patient.
How to fill out myocardial perfusion scan request?
To fill out a myocardial perfusion scan request, the healthcare provider must include patient identification information, clinical history, indications for the test, and any relevant medical data necessary for interpretation.
What is the purpose of myocardial perfusion scan request?
The purpose of a myocardial perfusion scan request is to assess the blood flow to the heart muscle, identify areas of ischemia, and evaluate heart function in patients with suspected coronary artery disease or other cardiac conditions.
What information must be reported on myocardial perfusion scan request?
The requested information typically includes patient demographics, medical history, specific indications for the scan, medications, and any previous test results relevant to the patient's cardiac health.
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