Download Magnetic Resonance Imaging - Non-Fasting - MCS6516-007

Magnetic Resonance Imaging (MRI)
Non-Fasting
You have been scheduled for a magnetic resonance imaging (MRI) exam that does NOT require fasting. You may take your
usual medications.
MRI cannot be performed if you have a cardiac pacemaker, defibrillator, aneurysm clip in the brain, cochlear implant,
implanted neurostimulator, or implanted TENS unit. If you have any of these implants, notify your physician immediately.
Please complete the enclosed MRI screening form and bring it with you to your exam. It will be necessary for you to
change into a gown that will be provided and to remove all metallic objects (i.e., jewelry, hairpins, wallet, hearing aid, etc.)
prior to the examination.
An MRI exam can take from 20 to 60 minutes. It is very important not to move for three to ten minutes at a time or that
portion of the exam may need to be repeated. If you have issues with claustrophobia or pain, it is beneficial to take any
required medications before you arrive for your exam. Please contact your physician for these medications prior to your
appointment.
MRI is a diagnostic scanning technique that produces detailed images of structures within the body. The MRI scanner is a
large cylindrical machine that creates a strong magnetic field and uses radio waves, not X-rays or radiation, to create the
images.
Based on the type of exam being performed, you may be allowed to listen to music. You are welcome to bring your
favorite compact disc for your listening pleasure.
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MCS6516-007rev1209
Outpatient Screening Magnetic
Resonance Imaging (MRI)
Page 1 of 1
Number (above) and Name
This form is meant to be filled out primarily by the patient and reviewed with the MRI staff.
Height ___________ cm
Weight __________ kg
Signature of Person Completing Document
Date (dd-Mmm-yyyy)
Form Completed by (if other, print name and relationship):
Patient
Relative
Other
Some of the following items may be hazardous to your safety and some can interfere with the MRI examination.
Please check the correct answer for each of the following. Do you have any of the following:
Aneurysm clip(s) in head
Yes
No Bone growth/fusion stimulator
Yes
No
Implanted Infusion pump for insulin or any other drug
Yes
No Polypectomy gastrointestinal clips within the last 90 days
Yes
No
Any implant held in place by magnet
Yes
No Brain, spine or peripheral nerve neurostimulator
Yes
No
Implanted metal hardware (wires, mesh, rods,
Spine
or
cerebrospinal
fluid
shunt
or
ventriculostomy
Yes
No
Yes
No
screws, plates)
Any type of prosthesis (e.g. eye, penile, limb)
Yes
No Breast reconstruction expanders
Yes
No
Internal cardiac pacing wires
Yes
No Cochlear, otologic, or any other ear implant
Yes
No
Back or extremity brace (remove before MRI)
Yes
No Tattoos/tattooed cosmetics (e.g. eyeliner, lips)
Yes
No
Intra-uterine contraceptive device (IUD) or Pessary
Esophageal/Reflux
Management
Systems
(e.g.
LINX)
Yes
No
Yes
No
Body piercing(s), if possible remove before MRI
Yes
No Gastrointestinal pill camera within last 90 days
Yes
No
Intravascular stents, filter, prosthetic heart valve
Yes
No Hearing aid (remove before MRI)
Yes
No
Other
Patient History
Have you ever had an MRI before?
Do you now, or have you EVER had an implanted
cardiac pacemaker?
Do you now, or have you EVER had an implanted
cardiac defibrillator (ICD)?
Do you have Kidney Disease?
Are you or have you ever been on dialysis?
Are you on a solid organ transplant list?
If yes, which organ?
Have you had a liver transplant in last 3 months?
Do you have diabetes?
Have you had previous lumbar spine/lower back surgery?
If yes, provide date of most recent surgery
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Have you had a previous brain surgery?
If yes, provide date of most recent surgery
Do you have a history of cancer?
If yes, what type of cancer?
Do you now, or have you ever had any injury to the
eye involving a metallic object?
Do you have any metal fragments (bullet/shrapnel/BBs)?
Are you pregnant?
Are you breast-feeding?
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Are you wearing any medication skin patches?
Are you wearing any wound dressings?
Yes
Yes
No
No
Before your MRI, please remove all metallic objects, including keys, hair pins, barrettes, jewelry, watch, safety
pins, paperclips, money clips, credit cards, coins, pens, belts, pocket knife and clothing with metal in the
material. Please note that you are required to wear earplugs and/or headphones during the MRI examination.
Official Use Only
Creatinine ________/eGFR __________ Date/Time ____________________
Reviewed by/Technologist Signature
*MCS15152*
Date (dd-Mmm-yyyy)
MCS15152