Mri Patient History And Screening Form
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1MRI PATIENT HISTORY AND SCREENING FORM
Patient Name: ______________________________
Follow Up Appt:________________________
D.O.B: ____/_____/_____ Age: _______ Weight: _________ Ht: ____________
Sex: M / F
Reason you are here today? Explain your medical problem in detail. (What is the problem? Where is the problem? Etc...)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Is your problem related to an injury?
Yes
No
If yes, Date of injury? _______________________
How were you injured?
Work
Motor Vehicle Accident
Other
Have you taken any sedation/alcohol today to relax you for this procedure?
Yes
No If yes, what? _______________________________
Do you have or have you ever had any of the following?
Yes
No
Cardiac Pacemaker
Yes
No
Heart Surgery/Heart Valve: If Yes, explain: ________________________________________________________________
Yes
No
Implanted Cardiac Defibrillator (ICD): ____________________________________________________________________
Yes
No
Brain Aneurysm Clips/ Brain Surgery: If Yes, explain: _______________________________________________________
Yes
No
Shunts/Stents/Filters/Intravascular Coil: ___________________________________________________________________
Yes
No
Eye Surgery/Implants/Spring/Wires/Retinal Tack: ___________________________________________________________
Yes
No
Injury to the Eye Involving Metal or Metal Shavings: _________________________________________________________
Yes
No
Orthopedic Pins/Screws/Rods/Joints/Prosthesis: _____________________________________________________________
Yes
No
Neurostimulator/Biostimulator: ___________________________________________________________________________
Yes
No
History of Cancer or Tumors: When: _______________________ Where: _______________________________________
Yes
No
Radiation Therapy/Chemo Therapy: ______________________________________________________________________
Yes
No
Previous Back Surgery (Lumbar/Thoracic/Cervical): When: ____________________________Levels: _______________
Yes
No
Ear Surgery/Cochlear Implants/Hearing Aids/Stapes Prosthesis: _______________________________________________
Yes
No
Vascular Access Port/Catheter: ___________________________________________________________________________
Yes
No
Metal Mesh Implants/Wire Sutures/Wire Staples or Clips/Internal Electrodes: ___________________________________
Yes
No
Electrical/Mechanical/Magnetic Implants? Type: ____________________________________________________________
Yes
No
Implanted Drug Infusion Pump/Insulin Pump: ______________________________________________________________
Yes
No
Are you Pregnant? When was your last Menstrual Period/Cycle? _______________________________________________
Yes
No
Tattoo’s/Permanent Make-up/Body Piercing/Patches: ________________________________________________________
Yes
No
Dentures/Partials/Dental Implants: ________________________________________________________________________
Yes
No
Gunshot Wounds/Shrapnel/BB: ___________________________________________________________________________
Yes
No
Breast Tissue Expander (Implanted Soft Tissue Retractors): ___________________________________________________
Yes
No
Do you have pins in your Hair/Clothes/Hair Extensions/Hair Pieces/Wig: ________________________________________
List any Drug Allergies: ________________________________________________________________________________________________
List Previous Surgeries: ________________________________________________________________________________________________
List any Medications you’re presently taking: ______________________________________________________________________________
MRI Contrast History:
Not applicable to this exam
Have you ever had MRI contrast?
Yes
No
Did you have any kind of reaction?
Yes
No If yes, explain: ____________________
Are you breast feeding at this time?
Yes
No
** Do you have any history of Renal disease?
Yes
No
** Do you have any history of Hypertension?
Yes
No
** Do you have any history of Diabetes?
Yes
No
**Have you ever had severe hepatic disease or liver transplant or pending liver transplant?
Yes
No
I attest that the above information is correct to the best of my knowledge. I have also informed the technologist that I am not pregnant at this time and I
give consent to have a contrast agent administered to me if needed for proper diagnosis of my procedure. I acknowledge that I am aware of the
possibility of side effects with contrast and I have had the opportunity to ask questions related to this form, to ask questions regarding the MRI
procedure, and I understand the information presented to me.
X_
______________________________________
______________________________________
_______________________________
Patient/Parent/Legal Guardian
MRI Technologist’s Signature
Date
FOR TECHNOLOGIST USE ONLY
Type of Contrast:
Contrast Temp: _____________________
Lot #:________ ______________
Expiration Date:
Time of Injection:
Amount:
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