Radioactive Iodine Referral Form

The following information is requested to aid in planning I-131 treatment for this patient. Please include any additional information that you feel may be relevant for the pre-treatment assessment of this patient.

Hospital:

Fax:

Client:*

First Last

Phone:*

Patient:*

Date & Time of Appt:

Medical History

Chronic Problems of Concern:

Diagnosis & Previous Treatment for Hyperthyroidism

When was the cat diagnosed and what symptoms lead to the diagnosis?

Has there been previous treatment?

Methimazole

What is the dosage?

Previous I-131 treatment

When was the cat treated?

Thyroidectomy

What date was the surgery performed?

Has there been evidence of adverse drug reaction to methimazole?

Has the client discontinued fish products at least 2 weeks before treatment?

Fish meal or oil as a minor ingredient is ok

Medications

Is the cat currently taking any medications other than methimazole? Please provide prescription information for each drug and specify whether the drug needs to be given while the cat is in our facility.