Mri Patient Screening Form Page 2
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2MRI Patient Screening Form - Part B
Patient Name:
Date of Birth:
Date:
\6ur physiaian or radiologist may deem it necessary for you to have an lV injection of a contrast agent containing
gadolinium to improve the quatity of your MR examination. Although gadolinium contrast agents have been used
safely in millions of patients, minor reactions (principally headache or nausea), and serious or life threatening
reactions may occur.
I have read and understand the above information, and have had my questions
answered. I agree to have the MRI procedure with injection of contrast if
deemed necessary.
Contrast Name
Amount
Lot #
History of previous reaction EYes o No
Exp. Date
lf Yes, Explain
Injection Site
Device Used
Patient Stated Weight
eGFR
(Range: Low = 30 High = > 60)
X5;"m"*;aam
Rate of Admin.
Tech lnitials
Post Injection Check: Time:_
Has patient's condition changed since injection? No
Yes _
lf Yes, specify change:
Are you'allergic to any medications,
o Yes tr No
lf Yes, please list:
seafood. or shellfish?
Barriers to Learninq
tr Yes
O No
Type:
lntervention:
tr Language
tr Interpreter Used
tr Hearing
tr Repeat Questions
tr Other
D Family/Significant
Other
E Patient unaware of current medications
tr Patient not on any medications
List anv medication(s} the patient has taken today and all current medications:
(lnclude over the counter, ointments, herbals, vitamins, birth control, etc,)
Y
10
Prior to release, patient was assessed and found impaired? O Yes tr No lf yes, Supervising Physician notified? O Yes tr No
lf patient refuses further assessment, notify Supervising Physician and Alliance personnel to follow policy #5023.
Commentsr
MINOR MODIFICATIONS BY RADIOLOGIST/PHYSICIAN
tr Yes tr No
Original Exam Order Ghanged to:
Ghanged by:
Date/Time:
Tech Signature:
Read Back Q Yes tr No Physician Signature:
Post Injection Instructions given (applicable to all patients who receive an injection).
D Yes
I
tto
Patient notified of rights and opportunity to "Speak up" with questions or concerns.
fl Yes
fl tto
Handoff Report given to next provider of care. Medication list provided if applicable.
I
Yes
fl lr|o
lnterviewer Signature
Title:
Tech Comments
Date:
Revised Januarv 1. 2010
AttachmentA00T
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