Mri Screening Form & Patient History
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MRI Screening Form & Patient History
Male
Female
Wt.
Patient Name:
Ht.
MRN:
DOB:
Age:
Procedure:
Referring Doctor
Reason for MRI
If yes, what kind?
Have you taken medication for this exam today
Yes
No
to relax you?
Have you had a previous MRI, CT, Ultrasound or x-ray related to this problem?
Yes
No
If yes, when and where were they done?
Have you had or do you have?
Yes
No
Heart surgery or stents put in? When?
Yes
No
A pacemaker or pacemaker wires left in?
Yes
No
Head Surgery? If yes, what was done?
Yes
No
Do you have aneurysm clips? If so, where?
Yes
No
Eye surgery or metal in eyes?
Yes
No
Ear surgery? Any implanted devices to aid your hearing?
Hearing aids? NOT ALLOWED IN MRI ROOM
Yes
No
Any electronic, mechanical or magnetic implanted devices? (Ex: insulin pump, neurostimulator, drug infusion,
Yes
No
bone or spine stimulator, defibrillator, etc.
Yes
No
Any foreign metal in your body?
(ex: shrapnel, ortho pins, screws, rods, BBs, filters?)
Yes
No
Cancer? What type?
Yes
No
Radiation therapy or chemotherapy?
Yes
No
Dentures or partials?
Yes
No
Tattoos, permanent make-up, body piercings? Where?
Are you in renal failure now?
Yes
No
Yes
No
Are you a renal dialysis patient? When do you dialyze?
Yes
No
Are you a transplant patient
(ex: liver, kidney, heart)?
Are you a diabetic?
Yes
No
continued on next page
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Parent category: Medical