Download MRI Screening and Clinical History

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
_______________
_______________
_______________
_______________
_______________
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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