Mri Patient Screening Form
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2MRI Patient Screening Form - Part A
Patient Label
Patient Name: ____________________________________
Date of Exam: _________________________________
Date of Birth: _____________________________________
Exam Ordered: ________________________________
Medical Record #: _________________________________
Diagnosis: ____________________________________
Patient Stated Weight: ______________________________
Pt. Address: __________________________________
Facility Name: _______________________________________ Patient’s Zip Code: _____________________________
Reason for Exam: ____________________________________________________________________________
PATIENT HISTORY
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.
*** Small Bowel Endoscopy Capsule
q No
History of Falls
q Yes q No
q Yes
*** Implanted Neurostimulators
q No
q Yes
If yes, most recent fall date
*** Implanted Cardiac Defibrillator
q No
q Yes
(past or present)
Asthma
q Yes q No
*** LVAD Device (Heart Pump)
q No
q Yes
Irregular Heartbeat
q Yes q No
** Pacemaker or Pacemaker wires
q No
q Yes
(past or present)
External Electrodes/Neurostimulators
q Yes q No
** Pregnant or Breast Feeding
q No
q Yes
(Tens-unit)
* Aneurysm Clips
q No
q Yes
(Verify and document safety or refer to the radiologist)
Vena Cava Umbrella Filter
q Yes q No
* Carotid Clips
q No
q Yes
GI tract procedure involving surgical clips q Yes q No
* Hypertension
q No
q Yes
(High Blood Pressure)
(Possible GI Clips may require x-rays)
* Vascular Clips/Grafts/Stents/Repair
q No
q Yes
History of Cancer (Patient)
q Yes q No
* Surgical Clips
q No
q Yes
* Infusion Pump
q No
History of Breast Cancer
q Yes q No
q Yes
* Programmable Shunt
q No
q Yes
If yes, any lymph nodes removed?
q Yes q No
* Iron deficiency or Anemia treated with Feraheme q Yes
q No
Metallic Implant/Prosthesis/Orthopedic Devices q Yes q No
* Metallic Foreign Body
q No
q Yes
Removable Hearing Aid
q Yes q No
(Gun shot wounds, metal shavings in eye, retinal buckle, etc.)
Epilepsy (Seizures)
q Yes q No
* Prior Ear or Brain Surgery
q No
q Yes
* History of severe hepatic disease
q No
Claustrophobia
q Yes q No
q Yes
(Consider GFR)
* Liver transplant
q No
q Yes
(Consider GFR)
Unable to Hold Still
q Yes q No
* Dialysis/Renal Failure/Renal Insufficiency
q No
q Yes
(Consider GFR)
Pins in Hair or Clothes
q Yes q No
* Diabetes
q No
q Yes
(Consider GFR)
Hair Extensions/Hair Pieces/Wig
q Yes q No
* Diabetic Pump
q No
q Yes
Braces or Oral Springs
q Yes q No
* Wound Dressing (i.e. Acticoat 7)
q No
q Yes
Removable Dental Work
q Yes q No
* Breast Tissue Expanders
q No
q Yes
Glitter/Permanent Eye Makeup
q Yes q No
* Artificial Heart Valves
q No
q Yes
Tattoos and/or Body Piercing
q Yes q No
* Heart Stents
q No
q Yes
Medication Skin Patches
q Yes q No
If yes to previous two questions document -
(Nitroglycerine, stop smoking, pain, birth control, etc.)
Date: _________________ Make: __________________________
Colored contacts must be removed.
Model: ________________________________________________
Check Box below if a previous imaging study completed was
Please list previous surgeries :
similar to body part being examined today
Previous MRI q Yes q No
Previous PET/PET/CT q Yes q No
Factors such as weight, body habitus and scan type
Previous CT q Yes q No
Previous X-Rays
q Yes q No
may determine if scan can be performed.
If yes Specify Area
I understand that I must remove all metallic items from my
____________________________________________________
person prior to the MRI exam and understand that failure to
____________________________________________________
do so can result in damage to those items and/or injury to
myself and others.
Patient Initials ____
___
Signature of Patient: ___________________________________________________ Date: ________________
(Parent or Guardian if patient is a Minor or Incapacitated)
Relationship:_____________________________________________
Interviewer’s Signature: ________________________________________________ Date: ________________
I have reviewed this information with the patient or their legal guardian, power of attorney, next of kin, etc.
Technologist’s Signature: _______________________________________________ Date: ________________
Revised January 1, 2012
Attachment A007
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