Buscopan Questionnaire

***Referring physicians – please fax completed form to 403-328-1218

Patient Name:
Date of Birth:
AHC #:    
Patient Height: in/cm   Patient Weight lbs/kgs

Medical Imaging Contrast – BUSCOPAN (Hyoscine-N-Butylbromide)

Buscopan is an antispasmodic agent used to help relax the digestive system including the bowel and gallbladder (biliary). These medications reduce the peristalsis (wave-like contractions) of smooth muscle resulting in relief from spasms in certain organs in the digestive system. This reduces the blurring and motion on the images and improves the quality of the examination. This medication is injected intravenously. In order to help us assess and minimize the possibility of side effects, please indicate yes or no for the following questions.

Do you have, or have you ever had any of the following? Please explain.

1. Glaucoma (untreated narrow angle)
Yes No
2. Myasthenia gravis (autoimmune neuromuscular disease)
Yes No
3. Prostate hypertrophy or other causes of urinary retention
Yes No
4. Cardiac arrhythmia (tachycardia), angina, cardiac failure, or any other cardiac history
Yes No
5. Megacolon
Yes No
6. Bowel obstruction or ileus
Yes No
7. Pyloric stenosis
Yes No
8. Reflux esophagitis
Yes No
9. Are you currently breastfeeding?
Yes No

For office use only:

Ordering Radiologist name (please print):

Date 06-21-2024


Administered by (if other than radiologist):

SPO2 Level: Pulse:

IV Buscopan amount mg Time:

*** Any “Yes” answers must be initialed by Radiologist before dispensing medication ***





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