Download Name - Alice Peck Day Memorial Hospital

MAGNETIC RESONANCE IMAGING
PATIENT SCREENING FORM
NAME__________________________________________________ DATE OF EXAM __________________ FACILITY NAME ________________
ADDRESS_______________________________________________ CITY__________________________ STATE ____ ZIP CODE__________
PHONE: DAY __________________ EVE _____________________ CELL_________________ DATE OF BIRTH ______________ SEX:
M F
WEIGHT ____________ ORDERING MD __________________________________INSURANCE TYPE/PRE-CERT #_____________________________
EXAM ORDERED:
SPECIFY BODY PART: ____________________________________________
SIDE OF INTEREST:
EFT
IGHT
CLINICAL HISTORY/SYMPTOMS______________________________________________________________________________________________
ATTENTION MR PATIENTS AND/OR FAMILY MEMBERS: THE MRI ROOM CONTAINS A VERY STRONG MAGNET. BEFORE YOU ARE ALLOWED TO ENTER, WE MUST
KNOW IF YOU HAVE ANY METAL IN YOUR BODY THAT CAN INTERFERE WITH YOUR SCAN OR BE DANGEROUS TO YOU.
QUESTIONS CAREFULLY
YES
YES
YES
NO
NO
NO
PACEMAKER, WIRES, OR DEFIBRILLATOR
PREGNANT OR POSSIBLY PREGNANT
COCHLEAR IMPLANT /INTERNAL HEARING AID
SO TO ENSURE YOUR SAFETY, PLEASE ANSWER THE FOLLOWING
YES
NO BRAIN / ANEURYSM CLIP
YES
NO IMPLANT WITH MAGNETS ANYWHERE
YES
NO NON REMOVABLE ELECTRICAL DEVICE (TENS)
IF YOU ANSWERED “YES” TO ANY OF THE QUESTIONS ABOVE YOU MAY NOT BE ELIGIBLE TO HAVE AN MRI EXAM.
PLEASE CALL AHCI AT 800-999-9154 TO VERIFY ELIGIBILITY
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
HAVE YOU HAD A COLONOSCOPY OR UPPER ENDOSCOPY IN THE LAST 2 MONTHS? WHERE? ______________________________________
HAVE YOU HAD AN MRI BEFORE?
WHEN? _______________ WHERE? ____________________BODY PART________________
DO YOU HAVE ANY DRUG ALLERGIES? IF YES, PLEASE LIST____________________________________________________________________
ARE YOU CLAUSTROPHOBIC?
PLEASE LIST ANY MEDICATIONS YOU HAVE TAKEN TODAY____________________________________
HAVE YOU HAD ANY BLOOD WORK DONE IN THE PAST 90 DAYS? IF YES, WHERE?______________________________________________
HAVE YOU EVER BEEN A MACHINIST, WELDER, OR METAL WORKER?
HAVE YOU EVER HAD AN INJURY IN THE FACE OR EYE WITH A METALLIC OBJECT?
HAVE YOU ALWAYS WORN EYE PROTECTION WHEN EXPOSED METAL WORKING?
PLEASE LIST ALL SURGICAL PROCEDURES WITH DATES THAT YOU HAVE HAD:
___________________________________________________________________________________________________
DO YOU HAVE ANY OF THE FOLLOWING?
YES
NO LATEX ALLERGY
YES
NO ORTHOPEDIC HARDWARE
YES
NO METAL SHRAPNEL, FRAGMENTS OR BULLETS
YES
NO CATARACT OR EYE IMPLANT
YES
NO COIL, FILTER, OR WIRE IN BLOOD VESSEL
YES
NO ARTIFICIAL LIMB OR JOINT
YES
NO TATTOOS OR TATTOOED EYELINER
YES
NO ARE YOU BREAST-FEEDING
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
INSULIN PUMP
IMPLANTED CATHETER, TUBE OR SHUNT
ARTIFICIAL HEART VALVE
PENILE PROSTHESIS
DIAPHRAGM OR INTRAUTERINE DEVICE
FOIL NITROGLYCERINE OR NICOTINE PATCHES
EAR OR BODY PIERCINGS
FALSE TEETH, RETAINERS, OR MAGNETIC BRACES
INFORMATION ABOUT GADOLINIUM CONTRAST:
YOUR EXAMINATION MAY REQUIRE AN I.V. INJECTION OF A CONTRAST AGENT CALLED GADOLINIUM. ALTHOUGH GADOLINIUM HAS BEEN USED SAFELY IN MILLIONS OF CASES,
MINOR REACTIONS (PRINCIPALLY HEADACHE OR NAUSEA) OCCUR IN ABOUT 2% OF PATIENTS, WHILE SERIOUS OR LIFE-THREATENING REACTIONS HAVE BEEN REPORTED IN
ABOUT 1 IN 400,000 PATIENTS. PEOPLE WITH A COMPROMISED RENAL SYSTEM HAVE EXPERIENCED A VERY SMALL RISK OF DEVELOPING A DISEASE CALLED NEPHROGENIC
SYSTEMIC FIBROSIS (NSF). TO DATE, NSF HAS OCCURRED IN PATIENTS WITH KIDNEY DISEASE AND THE VAST MAJORITY IF NOT ALL OF THOSE HAVE SEVERE OR END
STAGE RENAL DISEASE.
YES
YES
YES
NO HAVE YOU HAD A PREVIOUS ALLERGIC REACTION?
TO X-RAY, CT OR MRI CONTRAST MATERIAL
NO DO YOU HAVE A HISTORY OF ASTHMA?
NO HAVE YOU HAD AN INJECTION OF GADOLINIUM IN
THE PAST 7 DAYS?
YES
YES
YES
YES
NO ARE YOU BEING TREATED FOR KIDNEY DISEASE?
NO ARE YOU CURRENTLY UNDERGOING DIALYSIS?
NO DO YOU HAVE A HISTORY OF HYPERTENSION?
NO ARE YOU A DIABETIC?
I ATTEST THAT THE ANSWERS I HAVE PROVIDED TO QUESTIONS ON THIS FORM ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I HAVE READ AND UNDERSTAND THE
ENTIRE CONTENTS OF THIS FORM AND HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THE CONTENT OF THIS FORM. I AUTHORIZE AHCI PERSONNEL TO
ACCESS ALL PERTINENT MEDICAL INFORMATION NECESSARY TO PERFORM THIS EXAM.
SIGNATURE (PARENT/GUARDIAN) ____________________________________________________ DATE____________________________
MUSIC IS AVAILABLE TO LISTEN TO DURING YOUR EXAM. PLEASE FEEL FREE TO BRING A CD OF YOUR OWN IF YOU WOULD LIKE.
AHCI APPROVAL ___________________ DATE __________
EXAM NOTES_________________________________________________________
Rev 11/10