Interventional Radiology Patient Intake Form

This specialized intake form is designed for interventional radiology departments and practices that perform image-guided minimally invasive procedures such as angiography, embolization, biopsies, tumor ablations, and vascular interventions. The form systematically collects essential patient information including previous imaging studies, contrast media reactions, kidney function history, bleeding disorders, and current anticoagulation therapy that directly impacts procedural safety and planning.

The template includes dedicated sections for vascular access history, previous IR procedures, implanted devices that may affect imaging, and procedure-specific risk factors. It streamlines pre-procedure screening by capturing allergies to contrast agents and local anesthetics, renal function indicators, coagulation status, and medications that affect bleeding risk. This comprehensive approach ensures IR teams have all necessary clinical information to plan safe procedures, minimize complications, and optimize patient outcomes for complex image-guided interventions.