Na

me:M Br
ianDunl
op(
pat
ie
nt2)

Na
mak
elompok:

1.Al
vi
rac
hae
runi
ss
a(201802003)

2.I
ft
it
ahs
ail
yza
kia
h(201802
022)

No Ye
s No N/
A

1 Ha
vey
oue
verha
dana
sthma
? ✔

2 Ar
eyoua
ll
erg
ict
oanydr
ugorf
oood? ✔

3 Haveyoue
verha
dani
nje
cti
onofX-
rayc
ont
rat ✔
s
be
fore?

4 Doy
ouha
vehe
artdi
sea
se? ✔

5 Doy
ouha
vek
idne
ydi
sea
se? ✔

6 Ar
eyoudi
abe
ti
c? ✔

7 Ar
eyoutak
inga
nyme
dic
ati
onf
ordi
abe
tesa
tthe ✔
moment
?

8 Ar
eyoupr
egna
ntorbr
eas
tfe
edi
ng? ✔

Iti
simport
antt
hatyouunderst
andther i
skstha tmayas
soc
iat
edwitht
hisproc
edure.Occas
ional
ly,a
pat
ientmayhavemil
dall
e r
gicre
acti
onss ucha saras
horsnee
zing
.Veryrarel
y,apati
entma yhavea
mores e
ver
ereac
ti
onsuchasa nast
hmaa tt
ack.Plea
sest
ayint
hewa i
ti
ngroomf or30minut
e saf
tert
he
i
nject
ionofX-r
aycont
rastf
orobserva
tion.

Na
me, Si
gna
tur
e Da
te

M Br
iandunl
op 02/
03/
2020