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Download MRI SCREENING CT CONTRAST SCREENING NUCLEAR
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PATIENT’S NAME: ________________________________ TODAY’S DATE:________________ PATIENT’S #:_____________________________________________D.O.B.:________________ PHYSICIAN: _____________________________________________________________________ CLINICAL HISTORY/INDICATION:____________________________________________________ _______________________________________________________________________________ 1888 BAY SCOTT CIRCLE ■ NAPERVILLE, IL 60540-1106 P: 630-717-3700 ■ F: 630-717-3701 ■ www.Napervillemri.com _______________________________________________________________________________ _______________________________________________________________________________ cc/NAME:______________________________________FAX NUMBER:____________________ PHYSICIAN’S SIGNATURE:________________________________________________________ ICD-9: MRI SCREENING CT CONTRAST SCREENING HISTORY OF WORKING WITH METAL DIABETES Iodine / CT Contrast Allergy (Please call our office) PREGNANT OCULAR TRAUMA RENAL DISEASE PREGNANT CEREBRAL ANEURYSM CLIPS OTHER NON-ORTHOPEDIC METAL IMPLANTS AGE OVER 65 GLUCOPHAGE/GLUCOVANCE PACEMAKER METALLIC FOREIGN BODY IN EYE BUN/CRE Testing @ 3T IF ANY OF THE ABOVE ARE CHECKED, BUN/ CREATININE WITHIN 30 DAYS IS REQUIRED. IV SEDATION BUN_______ Cr______ DATE___/___/_____ PRIORITY READING - Physician must provide a contact name and number. Otherwise, STAT reading will not be provided. INTRAVENOUS CONTRAST PER RADIOLOGIST DISCRETION (If you do not select this option, please select a contrast option where applic able.) MAGNETIC X CT SCAN X CARDIAC X X-RAY X X ULTRASOUND STRESS TESTS RESONANCE (MR) (Multidetector) ______________________________ _______________________________________________________________________________________________________________________________ wo w/wo BRAIN wo w/wo w BRAIN IAC’S ONLY wo _______________________________________________________________ w/wo SINUSES NUCLEAR MEDICINE Stress Test (Lexiscan) ORBITS for MRI ABDOMEN COMPLETE CHEST PA & LATERAL LIVER / GB / PANCREAS (RUQ) _______________________________________________________________ _____________________________________________________________________________________________________________________________________________________________ KIDNEY / BLADDER PHARMACOLOGIC ABDOMEN complete _______________________________________________________________ _______________________________________________________________ NUCLEAR MEDICINE THYROID w/wo w NECK SOFT TISSUE ABDOMEN KUB (1 view) w/wo ORBITS Stress Test (No Treadmill) _____________________________________________________________________________________________________________________________________________________________ w/wo BRAIN & IAC’S wo w/wo PITUITARY wo FACIAL BONES w CHEST _______________________________________________________________ wo w/wo CERVICAL SPINE w PE CHEST wo w/wo THORACIC SPINE wo w/wo w ABDOMEN / PELVIS 3 5 F/E TREADMILL Stress Test (EKG Only) CERVICAL SPINE SCROTAL / TESTICULAR THORACIC SPINE R L B LUMBAR SPINE PELVIC TRANSABD & TRANSVAG _______________________________________________________________ GROIN _____________________________________________________________________________________________________________________________________________________________ MUGA (EF Only) 3 5 F/E _____________________________________________________________________________________________________________________________________________________________ PELVIS OBSTETRICAL -1st TRIMESTER X NUCLEAR MEDICINE _____________________________________________________________________________________________________________________________________________________________ wo w/wo LUMBAR SPINE w/wo *BRACHIAL PLEXUS Renal Stone Study wo w/wo CT Urogram BONE SCAN R L B HIP OBSTETRICAL - 2nd / 3rd TRIMESTER _____________________________________________________________________________________________________________________________________________________________ wo *Intracranial MRA CERVICAL SPINE R L B KNEE BIOPHYSICAL PROFILE wo *Carotid / Neck MRA THORACIC SPINE R L B FOOT *CAROTID DOPPLER THYROID R L B ANKLE AORTA R L B _____________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________ wo w/wo *NECK SOFT TISSUE LUMBAR SPINE _____________________________________________________________________________________________________________________________________________________________ R L B SHOULDER I123 Uptake & Scan R L B SHOULDER wo w/wo ABDOMEN R L B ELBOW Tc99m Scan only R L B HAND wo w/wo PELVIS R L B WRIST GASTROINTESTINAL R L B WRIST UE LE MUSCULOSKELETAL STUDY SHOULDER R L B HIP HIDA Scan R L FINGER OTHER: wo w/wo *CHEST LE ARTERIAL DOPPLER ______________________________________________________________________________________________ ________________________________________________________________ R L B UE LE VENOUS DOPPLER ______________________________________________________________________________________________ ________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________ R L B _______________________________________________________________________________________________________________________________ R L B RIBS ECHOCARDIOGRAM ________________________________ ______________________________________________________________________________________________ ______________________________ R L B ELBOW R L B KNEE R L B WRIST R L B ANKLE R L B CLAVICLE ______________________________________________________________________________________________ ________________________________ R L B HUMERUS X BREAST IMAGING ______________________________________________________________________________________________ ________________________________ R L B HIP / OSSEOUS PELVIS R L B R L B KNEE CALCIUM SCORE DIGITAL MAMMOGRAPHY R L B ELBOW R L B ANKLE LUNG SCREENING SCREENING R L B FOREARM FOOT _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ R L B TIB-FIB CT ANGIOGRAPHY (CTA) DIAGNOSTIC R L B FEMUR R L B HUMERUS *CTA HEAD BREAST ULTRASOUND R L B TIB - FIB R L B FEMUR *CAROTID / NECK CTA R L TOES R L B FOREARM *THORACIC AORTA CTA R L B HAND *ABDOMINAL AORTA CTA FOOT *PELVIC CTA BONE DENSITY R L B UE LE *PERIPHERAL CTA DEXA _______________________________________________________________________________________________ ________________________________ ______________________________________________________________________________________________________________________________ ____________________________________________________________________ Notes: ________________________________ OTHER: ____________________________________________________________________ NOTE: UE = Upper Extremity LE = Lower Extermity w = with contrast wo = without contrast w/wo = with and without contrast * = requires icd-9 code R = right L = left B = bilateral (ie both sides) 3 = 3 views 5 = 5 views F/E = Flexion/Extension ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ X ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ R L B OTHER: ___________________________________________________________________________________________________________________________________________________________________________________________________________ OTHER: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ OTHER: COMMENTS: __________________________________________________________________________________________________________________________
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