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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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