Charter Radiology Mri Screening Form
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1MRI Screening Form
Name
DOB:
Age:
Weight:
Height:
Sex:
:
Reason you are here today? Explain your medical problem in detail.
Patient History
Have you had previous exams related to your symptoms?
Yes
No
If yes, where / when? ____________________
Have you had surgery to the body part being imaged?
Yes
No
If yes, what type? _______________________
Yes
No
History of Cancer or Tumors: When _______________ Where ________________________________
Yes
No
History of Dialysis or Renal Insufficiency/Kidney Problems: ___________________________________
Yes
No
Do you take medications for high blood pressure: __________________________________________
Yes
No
Diabetic?
Yes
No
Do you have any allergies?
Do you have or have you ever had any of the following?
Yes
No
Cardiac Pacemaker / ICD
Yes
No
Metal Mesh Implants / Wire Sutures
Yes
No
Heart Surgery / Heart Valve
Yes
No
Implanted Drug Infusion / Insulin
Yes
No
Brain Aneurysm Clips / Brain Surgery
Yes
No
Tattoos / Body Piercing / Patches
Yes
No
Neurostimulator / Biostimulator
Yes
No
Dentures / Partials / Dental Implants
Yes
No
Shunts / Stents / Filters / Coil
Yes
No
Gunshot Wounds / Shrapnel / BB
Yes
No
Orthopedic Pins / Screws / Rods / Joints
Yes
No
Eye Surgery / Implants / Wires
/ Prosthesis
Yes
No
Previous Back Surgery
Yes
No
Have you ever done any welding or
(Lumbar/Thoracic/Cervical)
grinding?
Yes
No
Ear Surgery / Cochlear Implants /
Yes
No
Injury to the Eye Involving Metal / Metal
Hearing Aids
Shavings
Yes
No
Electrical / Mechanical / Magnetic
Yes
No
Are you pregnant?
Implants?
Yes
No
Are you breast feeding at this time?
Acknowledgement of Notification of Privacy Practices (Please Read and Sign Below)
By signing below, you acknowledge the availability of our Notice of Privacy Practices pamphlet, which provides information
about how we may use and disclose your protected health information, and is compliant with the Health Insurance Portability
and Accountability Act of 1996 (HIPAA). We reserve the right to change the terms described, and should we do this we will
post the changes in all of our offices. You have the right to request restrictions on how your protected health information may
be used or disclosed for treatment, payment, or health care operations. We are not required to agree with your restrictions;
but if we do, we are bound by our agreement with you. Please Note: In accordance with Maryland law, we may destroy patient
charts 6 years after the last documented record. In the case of a minor, records must be retained until the patient reaches the
age of 18 plus 3 years, or for 5 years after the record was made, whichever is later.
Signature of Patient or Authorized Representative
Date
Witness
Date
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