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WARNING: THE MRI MAGNET IS ALWAYS ON! If exposed to the magnetic field, certain implants, medical devices, or objects in or on your body may become hazardous to you, may malfunction, or may interfere with the MRI procedure. DO NOT ENTER the MRI area if you have any concern regarding an implant, device, or object. cc GdName ___________________________________________ DOB____/_____/_____Age_ _ Weight ______lbs.Last name First name Middle InitialDid you take anxiety medication? Y_____ N_____ If yes, who will be driving you home? __________________________________List any drug allergies and type of reaction: ______________________________________________________________________Are you experiencing any new problems with your breasts? _________________________________________________________Do you have breast implants? Y_____ N_____ If yes, circle type: Right: silicone saline Left: silicone saline First date of last menstrual period: ___/___/___ or Post/Peri-Menopausal Y___N__ Have you had a hysterectomy Y___ N___Are you or could you be pregnant? Y_____ N_____ Are you currently breastfeeding? Y_____ N_____Do you have any kidney (renal) or liver (hepatic) problems? Y____ N____ If Yes, please explain: ___________________________ Do you have high blood pressure? Y____N____ Do you have Diabetes? Y ____ N_____ For office use: GFR __ Creatinine___ Date Collected ___________ Location Collected_______________Have you had an imaging exam with any type of contrast dye (gadolinium or iodinated contrast)?Yes___ No___ Have you ever had a reaction to any type of contrast or dye (gadolinium or iodinated contrast)? Yes___ No___If yes, please describe: ________________________________________________________________________Have you had prior surgery or an operation of any kind in the last 8 weeks? If yes, please indicate the type of surgery:____________________________________Yes___ No___Have you had an injury to your eye involving a metallic object or fragment (metallic slivers, shavings, foreign body, etc.)? Yes___ No___If yes, please describe: ____________________________________________________Have you ever been injured by a metallic object or foreign body (BB, bullet, shrapnel, etc.)?Yes___ No___If yes, please describe: ____________________________________________________Are you taking any type of oral contraceptives, hormone replacements, or having fertility treatments? Yes___ No___If yes, please describe: ____________________________________________________Please circle Yes or No if you have the following:Aneurysm clipYes No Tissue expander/implant spacerYes NoCardiac pacemaker Yes No Breast biopsy clip Yes NoCochlear implant or hearing aidsYes NoNeurostimulator deviceYes NoImplanted cardiac defibrillator Yes No Medication patchYes NoImplanted epicardial pacemeaker leadsYes No Tattoo/permanent makeupYes NoProsthetic heart valve or replacement Yes No Body piercingYes NoImplanted insulin or chemotherapy pump Yes No Prosthesis (eye, limb)Yes No Electronic or magnetically activated implant /device Yes No IUD, pessary, diaphragmYes NoVascular access port or catheterYes No Orthopedic hardwareYes NoShunt (spinal, ventricular) Yes No Harrington rodsYesNoMetallic stent, filter, or coil Yes No Dentures/removable dental workYes NoAre you:Do you have:Taking blood thinners or aspirin? Yes NoSeizure disorderYes NoTaking Tamoxifen/Arimidex/Femara?Yes NoInvoluntary movement disorder Yes NoClaustrophobic? Yes NoAsthma Yes NoI attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and have had the opportunity to ask questions regarding the information on this form and regarding the MRI procedure.Signature of patient or person completing form: ________________________________________ Date: ___________Relationship to patient: ______________________________ Medication Guide distributed to patient: ___________Witness/Technologist: _________ Reviewed & Approved by: _________ M.D. or R.T.(R)(MR) Date: ___________For office use: MR#____________ Lot#_______________ Study ID _______________ Ordering M.D. ___________ ................
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