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MRI Screening and Clinical History (PATIENT TO COMPLETE) Please check the following medical conditions that apply. ____ Pacemaker ____ Brain aneurysm surgery ____ Artificial heart valve ____ Ear surgery/Cochlear Implants/Staples Prosthesis ____ Heart Surgery ____ Personal history of cancer -- lf so, what type: ____ Ventricular shunt in brain ____ Removable dental work ____ Electrical/Mechanical implanted prosthesis, pumps or metal devices ____ Hearing aids (If so, PLEASE REMOVE NOW!) ____ Orthopedic pins, screws or metal plates ____ Implanted stimulators or defibrillators ____ Medical patches (ie Nicoderm, birth control patches, Nitroglycerin) ____ History of renal disease ____ History of metal injury to your eyes ____ History of welding, drilling, cutting, or sanding metal as a job ____ History of bullets, wire or shrapnel in your body ____ Drug/Latex allergies (lf so, please list ) _________________ ____ Are you Pregnant or Breast feeding? ____ Tissue expanders (breast) ____ Tattoos/Permanent Make-up/Body Piercing ____ None apply Patient Name: _________________________ DOB: ___________________ Describe your present symptoms, or describe injury to area being scanned. How long have you had this problem ? _______________ Have you had surgery on this area: □ Yes □ No Date(s) ________________ Type of Surgery(s) ________________________ Have you had prior diagnostic imaging studies or examinations: If yes, please list: Body part Date MRI CT Scan X-ray Ultrasound Nuc. Med. □ MRI Contrast History: □ Yes □ No Facility Not applicable to this section Have you ever had MRI contrast? Did you have any kind of reaction? Are you diabetic? Do you have any history of kidney (renal) insufficiency or failure? Are you currently on dialysis? □ □ □ □ □ Yes Yes Yes Yes Yes □ □ □ □ □ No No No No No _______________ _______________ _______________ _______________ _______________ ==================================================================================== I attest that the above information is correct to the best of my knowledge. X Patient/Parent/Legal Guardian MRI Technologist's Signature Witness (if pt. is unable to sign) Date Amount & Type of Contrast Lot Number Expiration Date PREMIER IMAGING Date Route