Patient Name



5391719-177136 MRI FOOTPatient Name: _______________________________________________________________________________________________________________________ Why are you having this exam (medical problem including symptoms)?___________________________________________________Which foot is being scanned today? RightLeftBothHave you had other studies of your foot? No YesIf so which study? MRICTX-ray ArthroscopyWhen was the study performed? __________________________________________________________________________Where was the study performed? _________________________________________________________________________What were the results? _________________________________________________________________________________How has your condition changed since this study? _________________________________________________________________________________________________________________________________________________________________Do you have pain in the foot? No Yes If yes – Where? ________________________________________________________________________________________When did the pain start? _________________________________________________________________________Is the pain from an injury or accident? No YesIf yes- Describe_________________________________________________________________________________Do you have swelling of the foot? No Yes Where? ___________________________________________________Do you have arthritis? No YesWhat type of arthritis? _____________________________________Do you have a mass or lump on the foot? No Yes Where? ___________________________________________________Was a biopsy performed? No YesWhat were the results?______________________________________Do you have an ulcer on the foot? No Yes Have you broken a bone in your foot? No Yes When? ___________________________________________________Have you had surgery on the foot? No Yes When? ___________________________________________________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? ____________________________________________________________ INCLUDETEXT "S:\\HSImaging\\Forms\\MRI\\Safety\\Safety Questionnaire.doc" \* MERGEFORMAT MRI Safety QuestionnaireATTENTION: 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. WARNINGIf 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.YesNoAneurysm clipCardiac pacemakerImplanted cardioverter defibrillator (ICD) Electronic implant or deviceMagnetically activated implant or deviceNeurostimulation systemSpinal cord stimulation systemBone growth or bone fusion stimulatorCochlear, otologic or other ear implantInsulin or drug infusion pumpPregnancyPrior eye injuryCurrent Medications: No Yes (list)_______________________________________________________________________________Allergies: No Yes (list)_______________________________________________________________________________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.Signed(Patient / Parent / Other)DateOFFICE USE ONLYHardwareQuestionnaireMedical and all radiology recordsChest frontal x-raySkull x-rayPhysical exam: scalp / chest / abdomenPregnancyQuestionnairePregnancy testNot applicable CAUTIONThe presence of any of the following may or may not exclude you from having an MRI.YesNoAny type of prosthesis (eye, heart valve, limb, penile, etc.) Eyelid spring or wireMetallic stent, filter, or coilShunt, vascular access port, or central lineRadiation seeds or implantsSwan Ganz or thermo-dilution catheterMedication patch (nicotine, birth control, nitroglycerine, etc) Any metallic fragment or foreign body (bullet, shrapnel, etc) [consent]Wire mesh implantTissue expander (e.g. breast) [questionnaire]Surgical staples, clips, or metallic suturesWound dressingJoint replacement (hip, knee, etc) Bone/joint pin, screw, nail, wire, plate, etcIUD, diaphragm, or pessaryDentures or partial platesTattoo or permanent makeup [consent]Body piercing jewelryHearing aidOther implant: __________________ Breathing problem or motion disorderDialysis Diabetes (LABS ARE REQUIRED FOR CONTRAST)History of renal (kidney) disease History of sickle cell diseaseClaustrophobiaHeight: _________________Weight: _________________PRINT Patient Name: ____________________________Name:MRN:DOB:Foreign BodyQuestionnaireOrbit x-ray (2 views)Verified by Date ................
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