Coronary CT Questionnaire

📋 Patient identity

LAST NAME :

FIRST NAME :

Date of birth :

Weight :

Height :

Address :

Home phone * :

Mobile * :

Email * :

* Required: at least one 10-digit phone number and a valid email address.

GP / Referring physician :

ℹ️ Information sheet — Coronary CT

What is a coronary CT?
A coronary CT is a CT scan of the coronary arteries (vessels supplying the heart). Medications are sometimes required to improve image quality.

⏱️ Preparation before the examination

Fast for 3 hours before the examination (water is allowed).
Avoid coffee, tea, energy drinks and tobacco for 12 hours before the examination.
Bring the list of your current medications.

💊 Medications administered before the examination

A beta-blocker (by mouth or intravenously) to slow the heart rate.
Natispray® (nitroglycerin spray) to dilate the coronary arteries.

⚠️ Possible side effects

Beta-blocker: slower heart rate, tiredness, light-headedness.
Natispray®: hot flushes, headache, drop in blood pressure.

These effects disappear quickly.

🔬 Procedure

The examination takes about 15 to 20 minutes.
An injection of iodinated contrast medium is required.
You may feel a brief sensation of warmth.

✅ After the examination

Drink water (at least 1 L over the day).
Resume normal activities unless your doctor instructs otherwise.

⚠️ Important information — Please read carefully

Your doctor has requested a coronary CT scan. This examination requires an injection of iodinated contrast agent. Please answer the following questions to help us provide the best care. Circle or tick the answer that applies to you.

🔬 Kidney function assessment (iodinated contrast agent)

Are you over 70 years old?

YES NO

Do you have a known kidney disease or kidney failure?

YES NO

Do you have high blood pressure or are you being treated for it?

YES NO

Do you have diabetes?

YES NO

🔵 If you answered YES to one or more questions above:

A blood test including a creatinine measurement is required before your examination can be performed.
(Prescription provided by the Medical Imaging Center reception)

⚠️ You MUST bring this blood test result on the day of your scan.

🚫 Contra-indications to beta-blockers

Severe asthma / decompensated COPD

Severe bradycardia — heart rate < 50 beats/min

Atrioventricular block without a pacemaker

Decompensated heart failure

Severe hypotension — systolic blood pressure < 100 mmHg

Known allergy to beta-blockers

🚫 Contra-indications to Natispray (nitroglycerin)

Severe hypotension — systolic blood pressure < 100 mmHg

Suspected right ventricular infarction / low cardiac output

Recent use of medication for erectile dysfunction
Sildenafil, Tadalafil, Vardenafil — within 48 h before the examination

Known allergy to nitrates

✍️ Patient declaration

I certify that I have personally completed this form, have read and understood its content, and give my consent for the examination to be carried out.

Full name :

Date :

Signature :

Please rotate your phone

CABINET TESLA — MEDICAL IMAGING CENTER

Cognac Clinic • Dr Pierrick MORALES