Patient Name



5391150-190500 MRI Chest , Abdomen, And/or PelvisPatient Name: _______________________________________________________________________________________________________________________ Why are you having this exam (medical problem including symptoms)?___________________________________________________What other studies have you had? MRICT Upper GI Ultrasound Barium EnemaWhen 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 YesWhat 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, No Yes Type of surgery? ___________________________________________abdomen, or pelvis?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? ________________________________________________________________________________________________________________________________________________________________________ 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: NoYes (list)_______________________________________________________________________________Allergies: NoYes (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 coil Shunt, vascular access port, or central lineRadiation 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 implantTissue expander (e.g. breast) [questionnaire] Surgical staples, clips, or metallic suturesWound dressing Joint replacement (hip, knee, etc) Bone/joint pin, screw, nail, wire, plate, etcIUD, diaphragm, or pessary Dentures or partial platesTattoo or permanent makeup [consent] Body piercing jewelry Hearing aidOther implant: __________________ Breathing problem or motion disorder Dialysis Diabetes (LABS ARE REQUIRED FOR CONTRAST)History of renal (kidney) disease History of sickle cell disease ClaustrophobiaHeight: _________________Weight: _________________PRINT Patient Name: ____________________________Name:MRN:DOB:Foreign Body Questionnaire Orbit x-ray (2 views)Verified by Date ................
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