Mri Patient Screening Form
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2MRI Patient Screening Form - Part A
MRI SERVICES PATIENT INFORMATION
Date of Exam:
Patient Name:
Date of Birth:
Exam Ordered:
Physician/Specialty:
Diagnosis:
Medical Record #:
Patient's Zip Code:
Patient Stated Weight:
Facility Name:
Reason for Exam:
PATIENT HISTORY
MRI CANNOT be performed if "Yes" is answered to triple asterisked (***) questions.
Double asterisked (**) require a signed contraindication release. Single asterisked (*) must be referred to radiologist.
** Pacemaker or Pacemaker wires
** Small Bowel Endoscopy Capsule
*** lmplanted Neurostimulators
*** lmplanted Cardiac Defibrillator
** Pregnant / Breast Feeding
* Aneurysm Clips
(Ve.ify and document safety o. refer to the radlologist)
" Carctid Clips
* Artificial Heart Valves
" Heart Stents
lf yes to previous two questions need -
Date:
Make:
Model:
* History of severe hepatic disease/liver transplanUpending
liver transplant (no contrast for perloperativo
liv6r pts.) tr Yes
tr No
* Hypertension
B Yes
Q No
* Vascular Clips/Grafts/Stents/Repair
tr Yes
D No
* Surgical Clips
tr Yes
O No
* Infusion Pump
tr Yes
D No
n Programmable Shunt
B Yes
O No
* Allergies to lV dye, seafood, shellfish
tr Yes
D No
" Dialysis/Renal Failure/Renal Insufficiency
tr Yes
O No
* lron deficiency or Anemia treated with Feraheme tr Yes
Q No
* Metallic Foreign Body
tr Yes
O No
(Gun shot wounds, metal shavlngs In ey€, retinal buckle, etc.)
* Diabetes
" Diabetic Pump
* Wound Dressing (i.e. Acticoat 7)
* Breast Tissue Expanders
Asthma
lrregular Heartbeat
External Electrodes/Neurostimulators
O Yes
tr Yes
tr Yes
tr Yes
tr Yes
O Yes
O Yes
fl Yes
O Yes
ON o
ON o
t rNo
ON o
ON o
t rNo
QN o
B N o
QN o
tr Yes ONo
O Yes DNo
O Yes DNo
tr Yes DNo
fl Yes trNo
tr Yes ONo
O Yes DNo
(Tens-unit)
Vena Cava Umbrella Filter
tr Yes D No
Latex Allergies
tr Yes tr No
History of Cancer
tr Yes ONo
Metallic lmplanUProsthesis/Orthopedic
Devices O Yes ONo
Removable Hearing Aid
O Yes trNo
Epilepsy (Seizures)
tr Yes O No
Uncooperative or Disoriented
D Yes O No
Claustrophobia
trYes DNo
Unable to Hold Still
tr Yes trNo
Braces
O Yes ONo
Removable Dental Work
tr Yes QNo
Glitter/Permanent Eye Makeup
O Yes DNo
Tattoos and/or Body Piercing
O Yes D No
Medication Skin Patches
O Yes flNo
(Nitroglycerine, stop smoking, pain, birth control, etc.)
Any history with a * or ** must be approved by
radiologisUsupervising physician
Time:
* Prior Ear or Brain Surgery
Please list previous surgeries :
trYes
Q No
Approved by:
Date:
Check Box below if a orevious scan completed was
similar to body part being examined today
Previous MRI
Previous CT
Previous PET/PETCT
Previous X-Rays
QYes
aNo
Et Yes
o No
oYes
oNo
t rYes
t rNo
lf yes Specify Area
Using the figures, please shade in the areas
affected by pain and/or numbness.
Signature of Patient:
Date:
(Parent or Guardian if patient is a Minor or Incapacitated)
I have reviewed this information with the patient or their legal guardian, power of aftorney, next of kin' etc.
Tech's Signature:
Date:
Revised January 1,2010
Attachment A007
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