Mri Patient Screening Form - 2016
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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
Height: ____________________ Weight: ___________________ lbs./kg.
Date of Birth
Date
Patient Address:
City, State, Zip:
Patient: Please complete all the information contained in this boxed section.
A ny Medical/Dental Procedures requiring sedation in the past 24 hours?...................................................
Yes
No
*** Small Bowel Endoscopy Capsule .................................. Yes
No
J oint 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
** Existing Pacemaker or Pacemaker wires .................... Yes
No
Braces or Oral Springs ........................................................... Yes
No
** Pregnant ........................................................................... Yes
No
Removable Dental Work ........................................................ Yes
No
* Implanted Neurostimulator ............................................ Yes
No
Glitter/Permanent Eye Makeup ............................................. Yes
No
* Artificial Heart Valves/Heart Stents ............................... Yes
No
Tattoos and/or Body Piercing ................................................ Yes
No
Hearing Aid.............................................................................. Yes
No
Date:
Make:
Clothing with Dri Weave, Dri Fit or Wicking Feature ........... 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 on or 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
Claustrophobic? .................................................................... Yes
No
* Recent colonoscopy or digestive system
Did patient pre-medicate for this exam? ............................
Yes
No
procedure involving surgical clips ................................. Yes
No
Does patient have a driver? ....................................
N/A
Yes
No
* Metallic Foreign Body
...... Yes
No
Please list all past surgeries and their dates:
(Gun shot wounds, retinal buckle, etc.)
* Eye injury involving Metal ............................................... Yes
No
* Prior Ear, Eye or Brain Surgery ...................................... Yes
No
I have answered the questions above accurately. I understand
Any previous imaging study related to the reason
that I must remove all metallic items including my cell phone
for today’s exam? ................................................................... Yes
No
prior to entering the MRI scan room and a secure area will be
provided for my personal belongings. Failure to remove such
Type of Exam
items can result in serious damage to those items and/or
injury to me and others.
Facility
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:
Diagnosis:
Reason for Exam/Clinical Symptoms:
Clinical Pause #1: Correct Patient
Correct Procedure
Correct Body Part
Lowest SAR Utilized
Technologist Comments
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 October, 2016
Attachment A007
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