Magnetic Resonance (Mr) Procedure Screening Form For Patients printable pdf download

MAGNETIC RESONANCE (MR) PROCEDURE

Patient Stamp

SCREENING FORM FOR PATIENTS

Brigham and Women’s Hospital, Department of Radiology

W A R N I N G

Certain implants, devices, or objects may be hazardous to you and/or may interfere with the

MR procedure. DO NOT ENTER the MR system room or MR environment if you have any

questions or concerns regarding an implant, device, or object. Consult the MRI Technologist

BEFORE entering the MR system room. THE MR MAGNET IS ALWAYS ON.

Please indicate if you have any of the following:

Ë Yes

Ë No

Cardiac Pacemaker

Ë Yes

Ë No

Implanted Cardiac Defibrillator (ICD) Cardiac Electrodes, Pacing Wires, Internal Electrodes

Ë Yes

Ë No

Aneurysm Clip(s)

Ë Yes

Ë No

Cochlear, Otologic or other Ear Implant

Ë Yes

Ë No

Tissue expander (e.g. breast)

Ë Yes

Ë No

Swan-Ganz or Thermo Dilution

Ë Yes

Ë No

Worked with Metal OR Metal Fragments in Eyes

Ë Yes

Ë No

Do you have Glaucoma and/or Eye Prosthesis or device (i.e. eyelid spring, wire, implant)

Ë Yes

Ë No

Any Metallic Fragment or Foreign Body

Ë Yes

Ë No

Heart Valve Prosthesis

Ë Yes

Ë No

Electronic Implant or Device

Ë Yes

Ë No

Neurostimulation and/or Spinal Cord Stimulator

Ë Yes

Ë No

Ë Yes

Ë No

SHUNT(S) - spinal/intraventricular/peritoneal and other, If

YES

Is it Programmable

Ë Yes

Ë No

STENT(S) - cardiac/carotid/renal/iliac and other____________________________________

Ë Yes

Ë No

Bone Growth/Bone Fusion Stimulator

Ë Yes

Ë No

Do you use an Infusion Pump (i.e. drug infusion device)

Ë Yes

Ë No

Artificial or prosthetic Limb

Ë Yes

Ë No

Wire Mesh Implant

Ë Yes

Ë No

Surgical Staples, Clips, or Metallic Sutures

Ë Yes

Ë No

Joint Replacement (hip, knee, etc.) Bone/Joint pin, Screw, Nail, Wire, Plate, Harrington Rod, IVC Filter or Other Implanted Metal Device

Ë Yes

Ë No

Ë Yes

Ë No (If Yes, 1.5T compatible only)

IUD, If YES, Is it copper

Ë Yes

Ë No

Diaphragm, or Pessary Unit

Ë Yes

Ë No

Dentures, Partial Plate, Magnetic Dental Implants or Hearing Aids

Ë Yes

Ë No

Magnetically-Activated Implant or Device

Ë Yes

Ë No

Body Piercing jewelry

Ë Yes

Ë No

Tattoo or Permanent Makeup

Ë Yes

Ë No

Medication Patch (Nicotine, Nitroglycerin, etc.)

Ë Yes

Ë No

Allergic to Latex

Ë Yes

Ë No

Penile Implants

Ë Yes

Ë No

Do you feel dizzy/weak, do you need assistance to walk and/or have fallen lately

Ë Yes

Ë No

Ë Yes

Ë No

Are you claustrophobic, If YES, did you take any meds

Ë Yes

Ë No

Ë Yes

Ë No

Have you ever had an MRI, If YES, did you have an MRI done today where contrast was used

Ë Yes

Ë No

Ë Yes

Ë No

Do you have poor IV access, If YES, do you have a port-a-cath that will need to be accessed

Ë Yes

Ë No

Are you currently on dialysis for kidney failure

Ë Yes

Ë No

Do you have any of the following conditions, If

YES

mark what you do have:

Ë Personal or family history of Kidney Failure

Ë Diabetes Mellitus, if

do you take prescription drugs to control diabetes Ë Yes Ë No

YES

Ë Awaiting or within 6 weeks of Liver Transplantation

Ë Multiple Myeloma

Ë Systemic Lupus Erythematosus

Ë End-Stage Liver Disease

PATIENT WEIGHT ____________ HEIGHT ____________

List any other surgery, implant, or device not mentioned above: _______________________________________________________________________

________________________________________________________________________________________________________________________________

What is your current medical condition or reason for test? ____________________________________________________________________________

________________________________________________________________________________________________________________________________

For FEMALE Patients:

When was the Date of your Last Menstrual Period_________________

Ë Yes

Ë No

Are you pregnant?

Ë Yes

Ë No

Are you Scheduled for Breast MRI

Ë Yes

Ë No

If YES, Did you have any outside MRI/mammogram(s) films brought today for comparison

IMPORTANT INSTRUCTIONS

Before entering the MR environment or MR system room, you must remove ALL metallic objects including hearing aids, dentures, partial plates, keys,

beepers, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paper clips, money clip, credit cards, bank

cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, and clothing with metallic threads.

Patient/Guardian Signature: ________________________________________________ Date:____ / ____ / ____ Time ______________

PLEASE CONTINUE ON BACK PAGE WHEN SCHEDULED FOR MRI CONTRAST ENHANCED STUDIES

0601409 (11/08)

Magnetic Resonance (Mr) Procedure Screening Form For Patients

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