Mri Screening Form

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EMPI #___________________
MRI SCREENING FORM
PATIENT NAME_________________________________ Height______ Weight_______DOB______________
What symptoms have prompted today's visit? ________________________________________________________
Yes
No
Cardiac pacemaker/Implanted Cardioverter Defibrillator (ICD)/Heart valve/Heart surgery:
Date/type
Yes
No
Shunts/Stents/Intravascular coil: Date/type
Yes
No
Ear or eye implants/surgery: Date/type
Yes
No
Injury to eye involving metal or metal shavings
Yes
No
Are you or do you suspect pregnancy? Or are you breast feeding?
Yes
No
Brain or brain aneurysm surgery: Date/type
Yes
No
Any electrical, mechanical, magnetic pumps, stimulators, and/or implants?
Date/type
Yes
No
Any body piercing jewelry?
Yes
No
Any breast tissue expanders?: Date/type
Yes
No
Shrapnel or metal fragments in skin or body?: Specify
Yes
No
Dentures/Hearing aid/Wig: Please circle which applies.
Yes
No
Any type of prosthesis (eye, penile, etc.)?: Date/type
Yes
No
History of cancer or tumors:
Yes
No
Radiation therapy/Chemotherapy:
Yes
No
Any allergies or any prior allergic reaction to MRI contrast/dye (Gadolinium)?: Specify
Yes
No
Respiratory, liver, or blood disorders: Specify
Yes
No
Any medication patches?: Specify
All other surgeries: Date/type
Please list dates and locations of prior imaging related to today's exam:
Office Use Only:
Yes
No
Patient is 60 or older
Creatinine level needed: YES
NO
Creatinine______Date__________
Yes
No
History of high blood pressure requiring medication
eGFR_______
 
Yes
No
History of diabetes mellitus
22g 20g
__________ by_________
IV site____________ Attempts_______
Yes
No
History of renal disease including:
Dialysis
Kidney Transplant
Single Kidney
Kidney Surgery
History of Kidney Cancer
Patient or Guardian Signature _________________________________________________ Date
IMI Tech Initials__________
ORIGINATED: December 2005
REVISED: 01/2007, 05/2007, 10/2012; 3/2014; 10/2014

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