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Home
About
Company Overview
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Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Search
Search
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
Menu
Home
About
Company Overview
Services
Dexa
CT scan
Mammo
MRI
Ultrasound
X-Ray
Forms
Order Form
Patient Forms
Insurance
FAQ
Careers
Contact Us
MRI History/Screening
"
*
" indicates required fields
MRI HISTORY
Date:
*
MM slash DD slash YYYY
Gender:
*
Male
Female
Name
*
First
Last
Date of Birth:
*
MM slash DD slash YYYY
Referring Physician:
*
Height:
*
Weight:
*
PATIENT HISTORY
Reason you are here today? (Please list the problem, the area(s) experiencing the problem and when it started)
*
Have you had any surgery on the area being scanned?
*
Yes
No
Type/date:
*
Any history of trauma or injury in the area we are scanning today?
*
Yes
No
Type/date:
*
Do you have a history of cancer?
*
Yes
No
Type/date:
*
Any prior imaging/scans on the body part we are scanning today?
*
Yes
No
Type/date/facility name:
*
Do you have any food or drug allergies?
*
Yes
No
List all:
*
Pre-medicated specifically for this study today?
*
Yes
No
Medication Name(s):
*
Time/date of last dose:
*
Physician Name who prescribed:
*
Have you ever had metal in your eye or removed from your eyes?
*
Yes
No
Please write the areas of your body where you feel pain/numbness/tingling/weakness
*
Please write the areas of your body you have implants or metal inside of or on your body
*
FEMALE ONLY:
Is there a possibility of pregnancy?
*
Yes
No
Last Menstrual Cycle:
*
How Far Along?
*
MRI Screening
Do you have any of the following: (Please Select)
Do you have any of the following:
*
Aneurysm clip(s)
IUD, diaphragm, or pessary
Cardiac pacemaker
Artificial or prosthetic limb
Implanted cardioverter defibrillator (ICD)
Radiation seeds or implants
Electronic implant or device
Swan-Ganz or thermodilution catheter
Magnetically-activated implant or device
Medication patch (nicotine, nitroglycerine, etc)
Neurostimulation system
Any metallic fragment or foreign body
Spinal cord stimulator
Wire mesh implant
Internal electrodes or wires
Tissue expander (e.g. breast)
Bone growth/bone fusion stimulator
None
Do you have any of the following:
*
Cochlear, otologic, or other ear implant
Joint replacement (hip, knee, etc)
Insulin or other infusion pump
Bone/joint pin, screw, nail, wire, plate, etc.
Implanted drug infusion device
Dentures, implants or partial plates
Any type of prosthesis (eye, penile, etc)
Tattoo, permanent makeup, magneƟc lashes
Heart valve prosthesis
Body piercing jewelry
Eyelid spring or wire
Hearing aid (remove before entering MR room)
Metallic stent, filter, or coil
Shunt (spinal or intraventricular)
Breathing problems or motion disorder
Vascular access port and/or catheter
Other implant
None
Other implant:
*
Make:
Model:
Implant Date:
Make:
Model:
Implant Date:
WARNING:
Certain implants, devices, or objects may be hazardous to you and/or may interfere with MR procedure (i.e., MRI, MR angiography).Do not enter the MR system room or MR environment if you have any question or concern regarding an implant, device, or object. Consult the MRI Technologist or Radiologist
BEFORE
entering the MR system room. The MR system magnet is
ALWAYS
on. Before entering the MRI environment or MRI system room, you must remove all metallic objects including hearing aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paper clips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners and clothing with metallic threads. Safety risks from Radiofrequency (RF) waves include potential tissue heating and burns. Alert the scanner operator immediately if warming occurs. Please note that some warming is normal but you should never be uncomfortable.
Important Note:
The noise generated by scanning may reach a level in the scan room and in the bore of the magnet that can result in temporary (and occasionally) permanent hearing loss. Any patient who undergoes an MRI, as well as anyone in Zone 4 during a Scan,
MUST
wear hearing protection. Your exam may be monitored for quality assurance.
I aftest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MRI procedure I am about to undergo.
Signature of person completing form:
*
Date:
*
MM slash DD slash YYYY
Form Completed by:
*
Patient
Relative
Nurse/Caregiver
Printed Name:
Office Use Only:
Technologist/Credentials:
Date:
MM slash DD slash YYYY