Download Chest , Abdomen, And/or Pelvis

MRI Chest , Abdomen, And/or Pelvis
Patient Name: _______________________________________________________________________________________________________________________
Why are you having this exam (medical problem including symptoms)?___________________________________________________
What other studies have you had?  MRI CT
 Upper GI
 Ultrasound
Barium Enema
When was the study performed? __________________________________________________________________________
Where was the study performed? _________________________________________________________________________
What were the results? _________________________________________________________________________________
How has your condition changed since this study? ____________________________________________________________
_____________________________________________________________________________________________________
Have you had radiation therapy?
 No
Yes
What body part? ___________________________________________
Have you had chemotherapy?
 No
Yes
What body part? ___________________________________________
Any injury to your chest, abdomen, or pelvis?  No Yes
When? ___________________________________________________
Have you had any organ removed?
 No
Yes
Which Organ? _____________________________________________
Have you had an organ transplant?
 No
Yes
Which Organ? _____________________________________________
Have you had surgery of your chest,
abdomen, or pelvis?
 No
Yes
Type of surgery? ___________________________________________
When was your surgery? ____________________________________
Have you had any type of cancer?
 No
Yes What type? __________________________________________________
When was it diagnosed? ____________________________________
Where was it located? _______________________________________
What kind of treatment did you have? __________________________
When was your last treatment? _______________________________
Any other medical problems you are seeing the doctor for? ____________________________________________________________
____________________________________________________________________________________________________________
REVISED 05/15/2017
MRI Safety Questionnaire
ATTENTION: Certain implants, devices, or objects may prevent you from approaching the MRI machine. Before entering
the scanning room, please indicate if you do or do not have any of the items listed below and sign your name. Feel free
to ask the MRI personnel for clarification.
 WARNING
If you have one or more of the following, approaching
the MRI scanner may cause serious harm or even death.
Please tell the MRI personnel immediately.
Yes
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Aneurysm clip
Cardiac pacemaker
Implanted cardioverter defibrillator (ICD)
 Electronic implant or device
Magnetically activated implant or device
Neurostimulation system
Spinal cord stimulation system
Bone growth or bone fusion stimulator
Cochlear, otologic or other ear implant
Insulin or drug infusion pump
Pregnancy
Prior eye injury
Current Medications:  No
Yes (list)___________________________________
____________________________________________
Allergies:  No
Yes (list)___________________________________
____________________________________________
 CAUTION
The presence of any of the following may or may not
exclude you from having an MRI.
Yes
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Any type of prosthesis
(eye, heart valve, limb, penile, etc.)
Eyelid spring or wire
Metallic stent, filter, or coil
Shunt, vascular access port, or central line
Radiation seeds or implants
Swan Ganz or thermo-dilution catheter
Medication patch
(nicotine, birth control, nitroglycerine, etc)
Any metallic fragment or foreign body
(bullet, shrapnel, etc) [consent]
Wire mesh implant
Tissue expander (e.g. breast) [questionnaire]
Surgical staples, clips, or metallic sutures
Wound dressing
Joint replacement (hip, knee, etc)
Bone/joint pin, screw, nail, wire, plate, etc
IUD, diaphragm, or pessary
Dentures or partial plates
Tattoo or permanent makeup [consent]
Body piercing jewelry
Hearing aid
Other implant: __________________
Breathing problem or motion disorder
Dialysis
Diabetes (LABS ARE REQUIRED FOR CONTRAST)
History of renal (kidney) disease
History of sickle cell disease
Claustrophobia
Important:
The MRI magnet is always on. Before entering the MR
environment you must remove all metallic objects.
These include hearing aids, dentures, partial plates,
keys, beepers, mobile phones, eyeglasses, hair pins,
barrettes, jewelry, body piercing jewelry, watches,
safety pins, paperclips, money clips, credit cards, bank
cards, magnetic strip cards, coins, pens, pocket knives,
nail clippers, tools, clothing with metal fasteners, and
clothing with metal threads.
Height: _________________
Weight: _________________
Signed
PRINT Patient Name: ____________________________
(Patient / Parent / Other)
Date
OFFICE USE ONLY
Hardware
 Questionnaire
 Medical and all radiology records
 Chest frontal x-ray
 Skull x-ray
 Physical exam: scalp / chest / abdomen
Pregnancy
 Questionnaire
 Pregnancy test
 Not applicable
Name:
MRN:
DOB:
Foreign Body
 Questionnaire
 Orbit x-ray (2 views)
Verified by
Date
REVISED 05/15/2017