Parathyroid Scintigraphy - European Association of Nuclear Medicine

Pregnancy
Women of childbearing potential should have their pregnancy status checked using a form
such as the example below:
QUESTIONNAIRE FOR ALL FEMALE PATIENTS OF CHILD BEARING AGE
(12 – 55 YEARS)
We are legally obliged under The Ionising Radiation (Medical Exposure) Regulations 2000
to ask females of child bearing age who are having a nuclear medicine procedure whether
there is any chance they may be pregnant or breastfeeding.
Prior to your test, please answer the following questions in order for us to comply with
these regulations:
PATIENT NAME ................................................................................................................................... D.O.B
1. Have you started your periods? (please tick appropriate box)
Y ❐ What is the date of your last period ...................................................................
N ❐ Please sign below and we can then proceed with your test
OR Have you finished your periods / had a hysterectomy (please tick appropriate box)
Y ❐ Please sign below and we can then proceed with your test
N ❐ What is the date of your last period
2. Is there any chance you may be pregnant (please tick appropriate box)
Y ❐ We will need to discuss your test with you before we proceed
Not sure ❐ We will need to discuss your test with you before we proceed
N ❐ Please sign below and we can then proceed with your test
3. Are you breastfeeding? (please tick appropriate box)
Y ❐ We will need to discuss your test with you before we proceed
N ❐ Please sign below and we can then proceed with your test