Mri Patient Screening Form

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MRI PATIENT SCREENING FORM
The information requested on this form is very important . Please answer all questions as thoroughly as possible.
The person completing this form is responsible for the accuracy of the requested information.
Patient Name: _____________________________ Appointment Date:_______________________
Date of Birth:_________________________
Weight:_______________________
YES NO
YES NO
CARDIAC PACEMAKER-NOTIFY TECH
Breast Tissue Expander
Implanted Cardiovascular Defibrillator
Penile Implant
Stent, Coil or Filter Location:
Date:
Neuro-Stimulation System
Aneurysm Clips Location:
Bone Growth/Bone Fusion Stimulator
Surgical Staples, Clips or Metallic Sutures
Middle Ear/Cochlear Implant
Carotid Artery Clips Date:
Left
Right
Both
Internal electrodes or wires
Prosthesis of any kind? Location:
Date:
Eyelid Spring or Wire
Foley catheter with temperature probe
Artificial Heart Valve Date:
Thermodilution Swan-Ganz catherter
Hearing Aid
Implanted Drug Infusion Pump
Intrauterine Device IUD
Medication Pump
Shunt: Spinal or Ventricular
Metal Fragments
(Shrapnel or gunshot Wound)
Fractured bones or spine treated with:
Location:
Date:
Metal Rods
Date:
Magnetically Activated Implant or Device?
Metal Plates
Date:
Allergic Reactions to IV Contrast?
Have you been/are you now being treated for kidney problems?
Metal Pins/screws
Date:
Ph Graph Probe
Are you pregnant or trying to get pregnant?
Medication Patch
Are you Breast Feeding?
Metal in eyes
Tattoos/Permanent Makeup Location:
Left
Right
Both
Body Piercing
Location:
Sickle Cell Anemia
Other Implants
Location:
EKG leads or test done recently
Wig or Hairpiece
Silver Impregnated wound dressing
Ingested camera pill
No one should enter the MRI scan room with any of the following items:
● Watch ● Metal Zippers ● Firearms ● Removable Dental Work ● Hearing Aid ● Keys/Coins ● Pocket Knife
● Hairpins/Accessories ● Pens/Pencils ● Belt Buckle ● Bra ● Purse/Wallet/Money Clip/Credit Cards
Signature of person completing form X_____________________________ Date:__________________
□
□
Form completed by:
Patient
Relative
MRI STAFF:
X___________________________
Signature of person reviewing form:
Were plain films obtained? _____________
Films cleared by:____________________________
CONTRAST:___________________ AMOUNT:_____________ LOT#__________________ EXPIRATION:___________

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