Mri Screening Form - Touchstone Medical Imaging
ADVERTISEMENT
1MRI Screening Form
PATIENT NAME:
PATIENT ID#:
LAST NAME
FIRST NAME MIDDLE
DOB:
SEX:
DATE OF SERVICE:
EXAM:__________________________________________________
What is your weight? ___________________________ What is your height?___________________________
Do you have any of the following?
□ Yes □ No Do you have a Pacemaker or Defibrillator? *** If yes, please notify our staff immediately. You may
not be able to have an MRI exam***__
□ Yes □ No
Are you wearing a drug patch? If yes, explain:______________________________________________
□ Yes □ No Heart surgery/Heart Valve? If yes, explain:_________________________________________________
□ Yes □ No Brain surgery/Brain Aneurysm Clip? If yes, explain:_________________________________________
□ Yes □ No Are you being treated for chronic renal (kidney) disease or on dialysis?
□ Yes □ No Shunts/Stents/Intravascular Coil?:________________________________________________________
Yes □
No Do you have dentures - Including Magnetic Dentures, retainers, or dental implants?
□
□ Yes □ No Ear surgery/Cochlear Implants/Hearing Aids?:_____________________________________________
Yes □
No Medication Pump/Drug Infusion/Insulin?:___________________________________________________
□
□ Yes □ No Tens Unit/Neurostimulator/Biostimulator?:__________________________________________________
□ Yes □ No Sickle Cell Anemia? ___________________________________________________________________
□ Yes □ No Have you had metal removed from your eyes?______________________________________________
____________________________________________________
□ Yes □ No Permanent Eye Makeup?
□ Yes □ No Do you have a prosthesis?______________________________________________________________
□ Yes □ No
Are you pregnant? ______________________________________________________________
□ Yes □ No Any history of Cancer? ________________________________________________________________
Please list or comment on any other metal you may have in your body:________________________________________
Clinical Information
Allergies: Medications____________________________
Food________________________________________
Existing Conditions: Heart
Diabetes
Asthma
Kidney/Dialysis
Stroke
Cancer
Tumor
Major Trauma
Previous Surgeries: Brain
Spine
Joint
Abdomen
Describe the problem you are having _______________________________________________________________
Have you had surgery in the area of the problem? ____________________________________________________
Have you had a previous scan of the area we are scanning today? Yes_______ No _________
If yes: Where? ___________________________________________________ Date:________________
CONSENT: I have answered all the questions to the best of my knowledge and understand the information presented
to me. I have also informed the technologist that I am not pregnant at this time.
Parent/Legal Guardian Signuature: _______________________________________Date:____________________
Reviewing Technologist Signature: _______________________________________Date:____________________
INTERNAL USE ONLY: Creatinine level_______________________________ (Normal level: 0.5 - 1.5)
GFR:_________________________IV:_____________________Guage:__________________CC:____________________
#
O f
P unctures:
_ ______________________________________
C overage
b y:___________________________________
Technologist:_________________________________________
L ot:_______________________Exp:________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical