Magnetic Resonance (Mr) Procedure Screening For Patients
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2MAGNETIC RESONANCE (MR) PROCEDURE SCREENING FORM FOR PATIENTS
Date _____/_____/_____
Patient Number ______________________
Name ______________________________________________
Age ________
Height ________
Weight ________
Last name
First name
Middle Initial
Date of Birth _____/_____/_____
Male
Female
Body Part to be Examined _________________________
month
day
year
Address ____________________________________________
Telephone (home) (_____) _____-________
City
____________________________________________
Telephone (work) (_____) _____-________
State
_______________________ Zip Code ___________
Reason for MRI and/or Symptoms ___________________________________________________________________________
Referring Physician __________________________________
Telephone (_____) _____-______________
1. Have you had prior surgery or an operation (e.g., arthroscopy, endoscopy, etc.) of any kind?
No
Yes
If yes, please indicate the date and type of surgery:
Date _____/_____/_____
Type of surgery _________________________________________________________
Date _____/_____/_____
Type of surgery _________________________________________________________
2. Have you had a prior diagnostic imaging study or examination (MRI, CT, Ultrasound, X-ray, etc.)?
No
Yes
If yes, please list:
Body part
Date
Facility
MRI
_________________________
_____/_____/_____
____________________________________
CT/CAT Scan
_________________________
_____/_____/_____
____________________________________
X-Ray
_________________________
_____/_____/_____
____________________________________
Ultrasound
_________________________
_____/_____/_____
____________________________________
Nuclear Medicine _________________________
_____/_____/_____
____________________________________
Other__________ _________________________
_____/_____/_____
____________________________________
3. Have you experienced any problem related to a previous MRI examination or MR procedure?
No
Yes
If yes, please describe: ________________________________________________________
4. Have you had an injury to the eye involving a metallic object or fragment (e.g., metallic slivers,
shavings, foreign body, etc.)?
No
Yes
If yes, please describe: ________________________________________________________
5. Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)?
No
Yes
If yes, please describe: ________________________________________________________
6. Are you currently taking or have you recently taken any medication or drug?
No
Yes
If yes, please list:_____________________________________________________________
7. Are you allergic to any medication?
No
Yes
If yes, please list:_____________________________________________________________
8. Do you have a history of asthma, allergic reaction, respiratory disease, or reaction to a contrast
medium or dye used for an MRI, CT, or X-ray examination?
No
Yes
9. Do you have anemia or any disease(s) that affects your blood, a history of renal (kidney)
disease, renal (kidney) failure, renal (kidney) transplant, high blood pressure (hypertension),
liver (hepatic) disease, a history of diabetes, or seizures?
No
Yes
If yes, please describe: ________________________________________________________
For female patients:
10. Date of last menstrual period:_____/_____/_____
Post menopausal?
No
Yes
11. Are you pregnant or experiencing a late menstrual period?
No
Yes
12. Are you taking oral contraceptives or receiving hormonal treatment?
No
Yes
13. Are you taking any type of fertility medication or having fertility treatments?
No
Yes
If yes, please describe: ________________________________________________________
14. Are you currently breastfeeding?
No
Yes
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