CT / CYSTOGRAM / IVP / VCUG QUESTIONNAIRE / CONSENT FORM NAME: _____________________________________ DATE OF BIRTH: _____________ SEX: M / F WEIGHT: _________ WHAT BODY PART IS TO BE EXAMINED? ________________________________________________________________ PLEASE DESCRIBE YOUR SYMPTOMS: __________________________________________________________________ HOW DID THIS OCCUR? _______________
- A |
J |K |
U |V |
Instructions for vestibular / auditory evaluationINSTRUCTIONS FOR VESTIBULAR / AUDITORY EVALUATION
Your physician has recommended ABR, ECoG, and VNG to help in your
diagnosis and treatment. The tests are performed in our Frisco office at 4401
Coit Road, Suite 411.
Auditory Brainstem Response (ABR):
This test evaluates the electrical impulses as they are generated in the inner ear
and travel along the nerve through the brainstem in response to sound
stimulation. Electrodes will be placed on your face and ears, and earphones will
provide clicking sounds as the sound stimulation. You will lie on a comfortable
table and be as still and relaxed as possible; falling asleep is even acceptable.
This test takes about 15 to 20 minutes.
The ECoG is a recording of the electrical potentials of the inner ear (cochlea) in
response to sound stimulation. The results of this test are used to assist in the
diagnosis of inner ear fluid disorders such as Meniere’s Disease and perilymph
fistula. You will experience the same conditions as the ABR (above). This test
takes about 30 to 45 minutes.
A VNG is a measurement of your eye movements during different conditions to
assess some brain functions and your vestibular system (parts of your inner ears
that monitor movement and balance). You will follow a dot of light on the wall with
your eyes through different movements, and you will move through different
positions like sitting, laying flat, and turning your head to the right and left. Warm
and cool air will also be introduced into your ear canals; these tests sometimes
induce dizziness but it typically lasts only a few minutes. The test takes about 1
to 1.5 hour.
Do not take the following medications/chemicals for 48 hours prior to the test:
• Dizziness medications (ex. Meclizine, Antivert, Dramamine, Zofran,
• Antihistamines/Decongestants (ex. Allegra, Xyzal, Zyrtec, Benadryl, Patanase • Sedatives/Tranquilizers (ex. Valium, Lortab, Lyrica, Neurontin, Ambien, • Anti-depressants/Anti-anxiety (ex. Prozac, Trazodone, Paxil, Wellbutrin, Lexapro, Diazepam, Zoloft, Effexor, Xanax, Ativan, Seroquel) • Tobacco
The above medications/chemicals will suppress the necessary responses and a
true diagnosis will not be possible. Other medications, such as those for
heart conditions or diabetes, should be taken as usual. Please contact us if
you have any questions regarding your current medications.
• Do not drink any caffeinated beverages (coffee, tea, or soda) for 24 hours
• Eat a light breakfast/lunch on the day of the test. • Wear comfortable clothes and bring a jacket/sweater if you tend to be cold- • It is advised that you arrange to have someone pick you up or have someone you could contact for pick up if you do not feel well after the evaluation. After your tests are scheduled, we will check your insurance benefits and inform you of the quote provided. A follow-up appointment with your physician will also be scheduled at a convenient time after tests have been fully analyzed (usually 24-48 hours later). Failure to follow pre-testing instructions may result in rescheduling. If testing needs to be interrupted or canceled because pre-test instructions were not closely followed, a $100 charge may be applied to your account. If testing needs to be canceled or rescheduled by you other than for an emergency, a 72 hour notice is required; failure to do so may result in a $100 charge to your account. If you have any questions, please contact our office at (972) 731-7654.
New Listings Change in insulin pump model Pharmac has recently started to fund insulin pumps and consumables. Prior to the listing of these devices, it was up to each DHB to decide how and indeed if they would fund them. The first pump to be listed was the Animas 2020; however this has now been upgraded to the Animas Vibe insulin pump and will be listed fully subsidised in the Pharmaceu