Wayne Mri Patient Screening Form
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2Patient Label
WAYNE MRI
PATIENT SCREENING FORM
PROCEDURE REQUESTED: _________________ REQUESTING PHYSICIAN: __________________
MEDICAL HISTORY:
List physical symptoms and duration: ______________________________________________________
____________________________________________________________________________________
Height:____ft.____in.
Weight:______lbs.
Allergies:_____________________________________
Possibility of Pregnancy: Yes □
No □
Asthma:
Yes □
No □
Personal History of Cancer: Yes □
No □
Hay fever:
Yes □
No □
Gastric Bypass Surgery:
Yes □
No □
Sickle Cell:
Yes □
No □
Currently breastfeeding:
Yes □
No □
Multiple Sclerosis:
Yes □
No □
Dialysis:
Yes □
No □
HAVE YOU EVER BEEN TOLD TO NOT HAVE AN MRI?
YES _____
NO _____
Please list ALL surgeries you have had since birth: _______________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Have you ever worked in a machine shop or similar environment where you may have been subjected to
small metal pieces? Yes □
No □
Have you ever been injured by anything metal that was not removed? Yes □
No □
THE FOLLOWING ITEMS CAN INTERFERE WITH MRI IMAGING AND SOME CAN ACTUALLY BE
HAZARDOUS TO YOUR SAFETY. PLEASE CHECK IF YOU HAVE ANY OF THESE ITEMS:
(PLEASE CHECK YES OR NO)
YES NO
YES NO
YES NO
□
□ Cardiac Pacemaker
□
□ Joint replacement
□
□ Metal mesh
□
□ Defibrillator
□
□ Metal plates, pins,
□
□ Tinted contacts
□
□ Brain clips
or screws
□
□ Tattooed eyeliner
□
□ Carotid clips (Poppen-
□
□ Dentures/Braces
□
□ Breast expanders for
Blaylock carotid
□
□ Shunts
breast reconstruction
vascular clamp)
□
□ Eye implants
□
□ Bladder stimulator
□
□ Abdominal clips
□
□ Wire sutures
Others: __________________________
□
□ Aortic clips
□
□ Shrapnel, shotgun
_________________________________
□
□ Neurostimulators
pellets, bullets
Have you recently had a small
(TENS unit)
□
□ Penile prosthesis
bowel study in which you
□
□ Vagus nerve stimulator
□
□ Harrington rod
swallowed a camera capsule?
□
□ Heart valve or
□
□ Any type of pain patch
Yes □
No □
heart stent
□
□ Nicotine patch
□
□ Insulin pump
□
□ Hearing aid(s) or
cochlear implant(s)
NOTICE: Failure to correctly and thoroughly comply with this questionnaire may place the patient’s health in jeopardy as well as
compromise the quality of the exam. I consent to the performance of this examination and the administration of contrast media as
required to satisfy my physician’s request.
ADDITIONAL QUESTIONS AND SIGNATURE FOR CONSENT ON BACK OF FORM
TURN OVER →
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