2015 Mri Patient Screening Form
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1
2MRI Patient Screening Form - Part A
Last Name
Factors such as weight, body habitus and scan type
may determine if scan can be performed.
First Name
Date of Birth
Date
Height: ____________________ Weight: ___________________ lbs./kg.
Patient Address:
City, State, Zip:
Patient: Please complete all the information contained in this boxed section.
Any Medical/Dental Procedures requiring sedation in the past 24 hours?...................................................
Yes
No
*** Small Bowel Endoscopy Capsule .................................. Yes
No
Joint Replacement/Implants ................................................. Yes
No
Orthopedic or Prosthesis Devices ........................................ Yes
No
*** Implanted Cardiac Defibrillator
................. Yes
No
(past or present)
Vena Cava Umbrella Filter ..................................................... Yes
No
*** LVAD Device (Heart Pump) ............................................. Yes
No
Pins in Hair or Clothes ........................................................... Yes
No
*** Breast Tissue Expanders ................................................ Yes
No
Hair Extensions/Hair Pieces/Wig .......................................... Yes
No
** Pacemaker or Pacemaker wires
............... Yes
No
(past or present)
Braces or Oral Springs ........................................................... Yes
No
** Implanted Neurostimulator ............................................ Yes
No
Removable Dental Work ........................................................ Yes
No
** Pregnant ........................................................................... Yes
No
Glitter/Permanent Eye Makeup ............................................. Yes
No
* Artificial Heart Valves/Heart Stents ............................... Yes
No
Tatoos and/or Body Piercing ................................................. Yes
No
Date:
Make:
Removable Hearing Aid ......................................................... Yes
No
Clothing with Metallic or Anti-Microbial Fibers? ................. Yes
No
Model:
Medication Skin Patches ....................................................... Yes
No
* Surgical Clips/Vascular Clips/Grafts/Stents/Repair .... Yes
No
History of Cancer.................................................................... Yes
No
Type:
If yes, what type? ___________________________________
* Medication Pump ............................................................ Yes
No
Anything in your body that you weren’t born with? ........... Yes
No
* External Tens Unit ........................................................... Yes
No
If not listed above, notify the Technologist.
* Aneurysm Clips ............................................................... Yes
No
Please list previous surgeries not already mentioned and their dates:
* Recent colonoscopy or digestive system
procedure involving surgical clips ................................. Yes
No
* Metallic Foreign Body
...... Yes
No
(Gun shot wounds, retinal buckle, etc.)
* Eye injury involving Metal ............................................... Yes
No
* Prior Ear, Eye or Brain Surgery ...................................... Yes
No
I have answered the above questions accurately. I
Any previous imaging study related to the reason
understand that I must remove all metallic items including my
for today’s exam? ................................................................... Yes
No
cell phone prior to entering the MRI scan room and a secure
Type of Exam
area will be provided for my personal belongings. Failure to
remove such items can result in serious damage to those
Facility
items and/or injury to me and others.
Patient Initials ________
Date
Signature of Patient:
Date:
Time:
(Parent or Guardian if patient is a Minor or Incapacitated)
Relationship:
MRI CANNOT be performed if “Yes” is answered to triple asterisked (***) questions. Double asterisked (**) require a signed informed consent.
Single asterisked (*) may require further discussion between radiologist & technologist. Document any verbal approvals on Part B.
Medical Record # / Accession #:
Facility Name:
Exam Ordered - MRI of:
Referring Physician/Specialty:
Diagnosis:
Clinical Pause #1 Conducted .........
Yes
No
Reason for Exam/Clinical Symptoms:
I have reviewed this information with the patient or their legal guardian, power of attorney, next of kin, etc. and performed a clinical pause.
Technologist Comments
Technologist’s Signature:
Date:
Revised January 1, 2015
Attachment A007
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