Tiêu đề ZCL-QMS4-309 Insulin Tolerance Test (ITT) Questionnaire.pdf ✅

Insulin Tolerance Test (ITT) Questionnaire Control No. : ZCL-QMS4-309 Issue Date : 12 th May-2025 Revision No. : 01 Authorized by Global Lab Director Controlled Document Page 1 of 4 Insulin Tolerance Test (ITT) Questionnaire Patient’s MR No: / IPR No: ___________________ Date: __________________ Name: _____________________________________ S/O, D/O: __________________ Age (years): _________ Gender: ____________ Contact: __________________ Referring physician: __________________________ Ward: __________________ Clinical Indication: ______________________________________________________________ Clinical History: Length of child at birth: Normal / Small for gestational age Short stature since how many years: ___________ Height of parents: Normal / Short Height of siblings: Normal / Short Previous history of fits: Yes / No History of any medication: ___________________________ History of previous treatment: ___________________________ Previous record of same test: ___________________________ Physical examination: Weight: _______ Kgs. Height: _______cm Pulse: __________ beats / min Related investigation: CBC: _________ TSH: ________ X-Ray wrist for bone age: _____________ Others:________________________________ Patient Preparation: 1. The patient should fast 10 hours (no calorie intake for at least 8 hours) 2. He / She can drink water but not milk and juices 3. Parents should come early morning in hospital and child will be admitted in Day care: 8:00 am. 4. Signs and symptoms of hypoglycemia explained to child and parents 5. Dose of insulin is calculated as per body weight. 6. 10% dextrose solution should be available. Contraindications (Yes or No): 1. Age > 60 years 2. Ischemic heart disease with abnormal ECG 3. Epilepsy 4. Grossly overweight patients 5. Severe panhypopituitarism, hypoadrenalism (0900 hours Cortisol < 100 nmol/l)
Insulin Tolerance Test (ITT) Questionnaire Control No. : ZCL-QMS4-309 Issue Date : 12 th May-2025 Revision No. : 01 Authorized by Global Lab Director Controlled Document Page 2 of 4 Time Glucose On Glucometer (mg/dl) Insulin Administration Time : _______________ Dose: ________________ Procedural Notes: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Insulin Tolerance Test (ITT) Questionnaire Control No. : ZCL-QMS4-309 Issue Date : 12 th May-2025 Revision No. : 01 Authorized by Global Lab Director Controlled Document Page 3 of 4 Any Unusual Happening during the Procedure: YES/NO If Yes (Details): _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________________ Discharge Notes: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________________ Laboratory investigations 0 min 30 min 45 min 60 min 90 min 120 min GROWTH HORMONE GLUCOSE (glucometer) GLUCOSE (automation)
Insulin Tolerance Test (ITT) Questionnaire Control No. : ZCL-QMS4-309 Issue Date : 12 th May-2025 Revision No. : 01 Authorized by Global Lab Director Controlled Document Page 4 of 4 CONSENT The details of the study and purpose of clinical information of my child have been explained to me by Dr. __________________, I hereby give consent for the aforementioned. Name of the person giving consent: __________________ Relationship to the patient: _________________________ Signature: __________________ Reviewed By: Name: ___________________________ Signature: ________________________