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Department of Nuclear Medicine

All dia Institute of edical Sciences, Bhopal

REQUISITION FORMJ

Date: UHID:
Sex
Name: Age:

Address Phone Number:

hical and other relevantfindings (To be filled by referring physician

Clinical Indication (What specific information is required ?

Consultant 1/C: Department:

No. of previous study:

If follow up, date and NM
OPD/Ward:

3. Endocrine
2. Cardiovascular
1. Skeletal Rest) Thyroid Scan
Myocardial Perfusion Imaging (Stress
+
Whole Body bohe scan -131 Whole Body Scan
Please specify the type of stress_
Three Phase bone scan RAIU (lodine uptake)
Parathyroid Scan (Sestamibi)
Myocardial Perfusion Imaging (Rest only)
MIBG Scan

5. Genitourinary 6. Nervous system

4. Gastrointestinal ECD/HMPAO Brain SPECT
ODTPA/EC scan
Gastric emptying
ODMSA Scan Brain tumor Imaging
G I Bleed scan
M e c k e > ' s scan DRCG

HIDA/Mebrofenin OTesticular scan

7. Miscellaneous
8. Radionuclide TheraPy 9. Other(Please specify
Lung(V/Q) Scan O-131 therapyfor Thyrotoxicosis
Lymphoscintigraphy
O-131 therapy for Ca Thyroid (s30 mCi)
Scintimammography
Bone pain palliation (Sm-153)

Name and signature of the referring physician:

Designation:
Date:

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 patie
T ATAATGeneral instructions for
1. i T A TY T 3T
2.

3.

4
.

6.

8.
9.

1. Please come along with this requisition form on the day of appointment.
schedule or need to change your
2. lo Come on the given time. If you cannot come as per the given
e
dppointment, you must inform as soon as possible, so that another patient can be accommoddeu
Please
bring all your previous clinical records and investigation reports
4, Female patients must declare their pregnancy status. Even suspicion of pregnancy mustbereve
Breast feeding mothers should take instructions from the examining doctor for further feeding of the body.
. ATter your clinical examination, you will be called for administrátion of a radiotracer. After that you have to wait till

you are called for investigation.

YOur waiting period to complete the entire investigation may be as long as 6 hours. So please bring food as required

by you.
8. Please do not leave the department until you are asked to do so. Sometimes the investigations may have to be
repeated for satisfactory results.
9. The radioisotope for your investigation comes from B.A.R.c. Mumbai. Sometimes due to unavoidable circumstances
it may not come in time. In such a case you will be givena new date for the investigation.
10. If any special preparation is needed for the test, it will be provided while giving appointment for the investigation.
Kindly strictly comply to the instructions given, else your investigation can be postponed.
11. The need to come fasting for the investigation will also be informed while giving appointment.

a T Ü E aT FT/ Date and time of appointme

Appointment given by:

faT &Tt/AËr, af
Special preparation/ Instructions, if any:

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