MRI PROCEDURE SCREENING AND CONSENT FORM

MRI PROCEDURE SCREENING AND CONSENT FORM
PATIENT’S NAME: ________________________________________________ DATE OF BIRTH:________________
ALLERGIES: ______________________________________________________________WEIGHT:_ ______________
YES NO IS THERE ANY POSSIBILITY YOU MAY BE PREGNANT? IF YES, HOW MANY WEEKS?
________ IF NO, DATE OF LAST PERIOD_________________________________________________
YES NO ARE YOU BREAST FEEDING?
YES NO HAVE YOU EVER HAD A PROBLEM WITH CLAUSTROPHOBIA?
YES NO HAVE YOU EVER DONE ANY WELDING OR GRINDING?
YES NO HAVE YOU IN YOUR LIFETIME, GOTTEN ANY METAL FRAGMENTS OR SHAVINGS IN YOUR
EYES, FACE, EARS, OR EXTREMITIES? (PLEASE CIRCLE) WHEN?_________________________
YES NO HAVE YOU EVER HAD CANCER OF ANY TYPE? IF YES, TYPE OF CANCER?
________________________________________________ WHEN?________________________________
HAVE YOU HAD RADIATION OR CHEMOTHERAPY? IF YES, ON WHAT PART OF YOUR
BODY?_________________________________________________________________________________
YES NO DO YOU HAVE ANY HISTORY OF DIABETES, HYPERTENSION, LIVER DISEASE,
RECURRENT URINARY TRACT INFECTIONS, OR POSSIBLE KIDNEY DISEASE?
YES NO HAVE YOU EVER HAD SURGERY? IF YES, PROCEDURE AND WHEN______________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
YES NO PLEASE DESCRIBE THE CURRENT PROBLEMS THAT YOU ARE HAVING AND LIST ANY
PRIOR STUDIES OR PROCEDURES RELATED TO THIS (YOU MAY USE PICTURE BELOW):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Right
Left Left Right
*CONTRAINDICATIONS
NO MRI IF THE FOLLOWING:
- PACEMAKER
- IMPLANTED INSULIN/DRUG PUMP
- SWAN GANZ CATHETER
- NEUROSTIMULATOR (TENS UNIT)
- BIOSTIMULATOR
*NEED STENT DOCUMENTATION PRIOR TO MRI
*PATIENTS MUST HAVE IV PUMPS REMOVED BEFORE MRI EXAM.
FRONT
BACK
PATIENT LABEL
SLM-4202-003 (2/2011) FRONT
NOT A PART OF THE PERMANENT MEDICAL RECORD
(OVER)

MRI Patient History Form
THE FOLLOWING ITEMS MAY INTERFERE WITH MAGNETIC RESONANCE IMAGING AND MAY BE
POTENTIALLY HAZARDOUS OR FATAL. DO YOU HAVE ANY OF THE FOLLOWING:
YES NO CARDIAC PACEMAKER / DEFIBRILLATOR / LOOP
YES NO SWAN GANZ CATHETER
YES NO INTERNAL PACING WIRES
YES NO BIOSTIMULATOR / BONE GROWTH STIMULATOR
YES NO NEUROSTIMULATOR (TENS UNIT)
YES NO ANEURYSM CLIP(S) WHERE?_______________________________________________________
YES NO INTRAVASCULAR STENTS, FILTERS, OR COILS WHEN AND WHAT TYPE?_____________
YES NO ARTIFICIAL HEART VALVE TYPE?_ __________________________________________________
YES NO VASCULAR ACCESS PORT AND/OR CATHETER
YES NO VASCULAR CLIP(S) WHERE?_______________________________________________________
YES NO INTRAVENTRICULAR OR SPINAL SHUNT
YES NO IMPLANTED INSULIN / DRUG PUMP
YES NO HEARING AID / COCHLEAR IMPLANT / MIDDLE EAR IMPLANT (PLEASE CIRCLE)
YES NO NlTROGLYCERIN PATCH
YES NO PENILE PROSTHESIS
YES NO ORBITAL / EYE PROSTHESIS
YES NO ARTIFICIAL LIMB OR JOINT WHERE?_______________________________________________
YES NO ANY ORTHOPEDIC ITEMS (i.e. PINS, RODS, SCREWS, etc.) WHERE?_________________
YES NO TATTOOED EYELINER
YES NO DIAPHRAGM / I.U.D.
YES NO BODY PIERCINGS WHERE?_________________________________________________________
YES NO DENTURES / PARTIAL PLATE
YES NO DENTAL BRACES
YES NO ANY IMPLANT HELD IN PLACE BY A MAGNET
YES NO BULLETS, PELLETS, B.B.’S, OR SHRAPNEL WHERE?_________________________________
YES NO ANY OTHER IMPLANTED ITEM / TYPE ________________________
BEFORE YOUR M.R.I. PLEASE REMOVE ALL METALLIC/MAGNETIC OBJECTS INCLUDING KEYS,
HAIRPINS, BARRETTES, JEWELRY, WATCH, SAFETY PINS, PAPERCLIPS, MONEY CLIPS, CREDIT CARDS
(WALLET), COINS, PENS, BELT, POCKET KNIFE, ANY METAL OBJECTS.
I HAVE ANSWERED THESE QUESTIONS TO THE BEST OF MY ABILITY AND I UNDERSTAND THAT
POSSIBLE INJURY COULD BE A RESULT OF MY WITHHOLDING VITAL INFORMATION. I CONSENT
TO UNDERGOING THIS MAGNETIC RESONANCE IMAGING EXAMINATION.
SIGNATURE OF PATIENT: _________________________________________ DATE:________________________
IF PATIENT UNABLE TO COMPLETE FORM, INFORMATION OBTAINED FROM:
______________________________________________ (FAMILY MEMBER OR LEGAL GUARDIAN).
VERIFIED BY ________________________________ R.N. DATE: ________________ TIME:__________________
SIGNATURE OF SCREENING TECHNOLOGIST: _______________________ DATE:_ _____________________
SLM-4202-003 (2/2011) BACK
NOT A PART OF THE PERMANENT MEDICAL RECORD
(OVER)
PATIENT LABEL