Mri Patient Screening Form printable pdf download

MRI Patient Screening Form - Part A

Patient Label or Accession Number

Factors such as weight, body habitus and scan type

may determine if scan can be performed.

Patient: Please complete all the information contained in this boxed section.

Patient Name (Last, First): ________________________________________________

Date of Birth: ______________

Patient Address: _______________________________________________________

Date of Exam: _____________

City, State, Zip: ___________________________________________ Patient Stated Weight: _____

Height: _____

lbs/kgs

Please list previous surgeries and their dates:

_____________________________________________________________

________________________________________________________________________________________________________

*** Small Bowel Endoscopy Capsule...............................q Yes

q No

Are you breastfeeding? ................................. q Yes q No

*** Implanted Cardiac Defibrillator

.............q Yes

q No

History of Falls within past 30 days.............. q Yes q No

(past or present)

If yes, most recent fall date

*** LVAD Device (Heart Pump) ..........................................q Yes

q No

Asthma or Chronic Heart Disease, CHF ....... q Yes q No

*** Breast Tissue Expanders ............................................q Yes

q No

Vena Cava Umbrella Filter ............................. q Yes q No

** Pacemaker or Pacemaker wires

..........q Yes

q No

(past or present)

History of Cancer............................................ q Yes q No

** Implanted Neurostimulator .........................................q Yes

q No

If yes, what type?

____________________

** Pregnant .......................................................................q Yes

q No

Joint Replacements/Implants ........................... q Yes q No

* Aneurysm Clips ...........................................................q Yes

q No

Orthopedic or Prosthesis Devices ................... q Yes q No

* Recent colonoscopy or digestive system

Epilepsy (Seizures)......................................... q Yes q No

procedure involving surgical clips ........................q Yes

q No

Claustrophobia ............................................... q Yes q No

(Possible GI Clips may require x-rays)

Pins in Hair or Clothes ................................... q Yes q No

* Surgical Clips/Vascular Clips/Grafts/Stents/Repair .. q Yes

q No

Hair Extensions/Hair Pieces/Wig .................. q Yes q No

_________________________________________

Type:

Braces or Oral Springs .................................. q Yes q No

* Medication Pump ........................................................q Yes

q No

Removable Dental Work ................................ q Yes q No

* External Tens Unit ........................................................q Yes

q No

Glitter/Permanent Eye Makeup...................... q Yes q No

* Metallic Foreign Body

...q Yes

q No

Tattoos and/or Body Piercing ........................ q Yes q No

(Gun shot wounds, retinal buckle, etc.)

* Eye Injury involving Metal ...........................................q Yes

q No

Removable Hearing Aid ................................. q Yes q No

* Prior Ear or Brain Surgery...........................................q Yes

q No

Medication Skin Patches ............................... q Yes q No

* Receiving treatment for gout? ....................................q Yes

q No

History of Diarrhea in past 2-3 days ............. q Yes q No

Iron deficiency treated w/Feraheme ............. q Yes q No

* Artificial Heart Valves/Heart Stents ............................q Yes

q No

Personal history of diabetes ......................... q Yes q No

If yes:

__________________

__________________________

Date:

Make:

Any previous imaging study related to the reason

Model: ____________________________________________________

for today’s exam? ..............................................

q Yes q No

I have answered the above questions accurately. I under-

stand that I must remove all metallic items prior to entering

Type of Exam

the MRI scan room and a secure area will be provided for my

Facility

personal belongings. Failure to remove such items can result

in damage to those items and/or injury to me and others.

Date

Patient Initials ____

___

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 Physican/Specialty: _____________________

Diagnosis: ____________________________________

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’s Signature:

Date:

Revised January 1, 2014

Attachment A007

Mri Patient Screening Form

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