Heidelberg Test Instructions

HEIDELBERG GASTRIC pH PRE- TEST QUESTIONNAIRE

Answer all questions below prior to scheduling the test. Bring this form with you to the test.

Please circle any of the following conditions that apply to you:

  1. I have a cardiac pacemaker.
  2. I am pregnant or think I may be pregnant.
  3. Crohn’s Disease
  4. Gastro-Intestinal Cancer
  5. Ulcerative Colitis
  6. GI bleeding
  7. Prior history of GI surgery
  8. GI adhesions or occlusions
  9. Prior history of chemotherapy or radiation

Please circle any of the following medications you have taken within the last seven days:

1.  PEPCID    6.  NEXIUM
2.  PRILOSEC    7.  TUMS
3.  PREVACID    8.  AXID
4.  TAGAMET    9.  PROTONIX
5.  PEPTO-BISMOL    10.  ZANTAC
Have you taken any other medication for your stomach in the last seven days?  Yes  No
    If Yes; what medication _________________________________________________________
Are you currently on antibiotics?  Yes  No
Have you taken any anti-histamines within the last two days?  Yes  No

STOP: If you circled or answered Yes to any of the above questions you MUST discuss your answers with the doctor BEFORE scheduling your test. Failure to do so will either lead to your test being canceled or invalid results if you fail to disclose any yes answers. This could be detrimental to your health. Please call to discuss.

PROCEED: You may schedule the test if you answered NO to all the above questions and DID NOT circle any conditions or medications.

HEIDELBERG GASTRIC Ph TEST INSTRUCTIONS

Please follow these instructions beginning the evening prior to the test:

1) If your test is scheduled in the morning- do not eat anything after 9:00PM the night before. Do not drink anything except water after 9:00PM the night before. Only drink a small amount of water the morning of the test if you must, no more than half a glass and none at all for a minimum of one hour
before the test. Do not ingest anything else the morning of the test (no food, other liquids, medications or nutriceuticals). Do not drink any soft drinks, coffee, tea or other beverages the day of the test.

2) If your test is scheduled for the afternoon- Have a small, light breakfast only before 8:00AM. This should be a low protein, low fat meal, consisting of cereal, fruit and vegetables only. Water, milk or fruit juice may be consumed in small quantities. Do not ingest anything else the morning of the test (no food, other liquids, medications or nutriceuticals). Do not drink any soft drinks, coffee, tea or other beverages the day of the test. Do not eat or drink anything else after your light breakfast, except for a few ounces of water. Only drink a small amount of water and none at all for a minimum of one hour before the test.

3) If you are taking prescription medications please advise the doctor BEFORE the day of your test. You may need to get permission from your prescribing physician to withhold your medication until the test is completed.

4) If you are taking an acid blocking (proton pump inhibitor) medication, you must discontinue it for 7 days before the test, or it will render the test invalid. Please discuss your options with the doctor before doing so. You may need to get permission from your prescribing physician to discontinue or switch medications.

5) If you are taking antacids such as Tums, you must discontinue it for 3 days before the test, or it will render the test invalid. Please discuss your options with the doctor before doing so. You may need to get permission from your prescribing physician to discontinue or switch medications

6) Do not take any anti-histamines, either prescription or over-the-counter for at least two days before the test or it will render the test invalid. Please discuss your options with the doctor before doing so. You may need to get permission from your prescribing physician to discontinue or switch medications.

7) Do not take the test if you are on antibiotics. Wait until you have completed your prescribed course of antibiotics before you take the test.

8) Thousands of pregnant women have taken the Heidelberg gastric pH test, with no reported difficulties. If you are pregnant or think you are pregnant, and you have ANY concerns, do not take the test.

9) If you have a cardiac pacemaker, do not take the test. If you have Crohn’s Disease, Gastro-Intestinal Cancer, Ulcerative Colitis, GI bleeding, prior history of GI surgery, GI adhesions or occlusions, prior history of chemotherapy or radiation, DO NOT take the test.

10) The Radio Transmitter is NOT radioactive. It transmits a radio signal, just like your cell phone. The Radio Transmitter Capsule will pass through your system and be expelled, like undigested food, in the feces. You DO NOT need to recover it. It is single use only!

Please ask ANY questions or address any concerns you have, prior to commencing the test.
Please bring this completed form with you the day of the test.

TEST DAY QUESTIONS (to be answered immediately prior to taking the test).

If you are taking the test in the morning:

1.  Did you eat anything today? ________________________________________
2.  Did you drink anything today? ______________________________________
3.  Did you take any nutriceuticals today? _____________________________
4.  Did you take any medications today? ________________________________

 
If you are taking the test in the afternoon:

1.  Did you eat anything after 8:00AM today? ___________________________
2.  What did you eat for breakfast______________________________________
3.  Did you drink anything today? ______________________________________
4.  What, how much and when did you last drink anything ________________
______________________________________________________________________
5.  Did you take any nutriceuticals today? _____________________________
6.  Did you take any medications today? ________________________________

 
Do you have any questions before you start the test?
 
PLEASE TURN OFF YOUR CELL PHONE AS IT MAY CAUSE INTERFERENCE.
THE TEST MAY LAST UP TO 90 MINUTES- PLEASE USE THE RESTROOM PRIOR TO COMMENCING, IF NECESSARY.

Informed Consent

The Heidelberg Gastric pH analysis test has been in use for over 30 years. It is used in clinics and research settings. Over one million tests have been performed to date with no reported serious adverse reactions or consequences. All medical tests carry a risk. The capsule may become lodged and not pass through your GI tract and be eliminated. This may cause serious consequences. This is an elective procedure. You are free to elect not to have this test performed if you have any concerns regarding its safety. By signing this you acknowledge that you understand and accept the potential risk associated with performing a Heidelberg Gastric pH Analysis.

Signed:_______________________________________Dated:______________