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Magnetic Resonance (MRI) Screening Procedure for PatientsPatient Name: ______________________________________________ Date of Exam: _____ /_____ /_________DOB: _____ /_____ /_________ Age: _______ Weight: ____________(lbs.) Height: __________ Sex: □ Female □ MaleMR# _______________________ Acc#: ____________________ Referring Physician: __________________________________1.) Why are you having the MRI test today? ________________________________________________________________________________________________________________________________________________________________________________________________________2.) Do you have a pacemaker or defibrillator? Yes □ No □3.) Have you had any surgeries or operations? Yes □ No □ Type(s) of Surgery and approximate date(s): _____________________________________________________ _________________________________________________________________________________________________4.) Have you ever experienced any problems with a previous MRI? Yes □ No □5.) Have you ever had an eye injury or do you have any metal in your body? Yes □ No □6.) Are you allergic to any medication? Yes □ No □ If yes, please explain: _______________________________7.) Have you ever had an allergic reaction to contrast media (dye)? Yes □ No □ 8.) Do you have kidney disease? Yes □ No □ (Transplant, blood or protein in urine, on dialysis, only one kidney)9.) Are you diabetic? If yes, circle which type: Type 1 Type II Yes □ No □10.) Do you have liver disease (transplant, cirrhosis or scarring)? Yes □ No □FEMALE PATIENTS1.) Are you (or is it possible) that you may be pregnant? Yes □ No □ Date of last menstrual period: _______________________2.) Are you currently breastfeeding? Yes □ No □-4699038100WARNING!!! Certain metallic implants, devices or objects may be hazardous to you and/or may interfere with the MRI procedure. Please DO NOT ENTER the MRI system room or MRI environment if you have any questions or concerns regarding any implant, device or object. Consult the MRI technologist or radiologist BEFORE entering the MRI system room. The MRI system magnet is ALWAYS on! Please indicate if you have any of the following: Yes No Aneurysm clip(s) Yes No Electronic implant or device Yes No Magnetically activated implant or device Yes No Neurostimulation system Yes No Spinal cord simulator Yes No Internal electrodes or wires Yes No Bone growth/bone fusion stimulator Yes No Cochlear, otologic or other ear implant Yes No Insulin or other infusion pump Yes No Implanted drug infusion device Yes No Any type of prosthesis (eye, penile, etc.) Yes No Heart valve prosthesis Yes No Eyelid spring or wire Yes No Artificial or prosthetic limb Yes No Metallic stent, filter or coil Yes No Shunt (spinal or intraventricular) Yes No Vascular access port and/or catheter Yes No Radiation seeds or implants Yes No Swan-Ganz or thermodilution catheter Yes No Medication patch (Nicotine, Nitroglycerine,etc.) Yes No Any metallic fragment or foreign body Yes No Wire mesh implant Yes No Tissue expander (e.g. breast) Yes No Surgical staples, clips or metallic sutures Yes No Joint replacement (hip, knee, etc.) Yes No Bone/joint pin, screw, nail, wire, plate, etc. Yes No IUD, diaphragm Yes No Dentures or partial plates Yes No Tattoo or permanent makeup Yes No Body piercing jewelry Yes No Hearing aid (please remove before entering MRI) Yes No Other Implant(s) _______________________________ Yes No Motion disorder Yes No Claustrophobia Yes No Other : _______________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________Please mark on the figure(s) below the location of any implant or metal inside of or on your body.184785203205538718605 IMPORTANT INSTRUCTIONS:Before entering the MRI environment or MRI system room, you MUST remove ALL metallic objects including hearing aids, dentures, partial plates, keys, beepers, cell phones, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, credit cards, bank cards, magnetic strip cards, coins, pens, pockets knife, nail clipper, tools, clothing with metal fasteners & clothing with metallic threads. Please consult the MRI Technologist or Radiologist if you have any questions or concerns PRIOR TO entering the MRI system room. NOTE: You may be advised or required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems related to acoustic noise. I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MRI procedure that I am about to undergo.Form completed by: □ Patient □ Relative________________________________________________ ___________________________________ _________________________________ Signature of Person Completing this Form Printed Name Relationship to Patient _____ /______ /_________ ________________________________________ _____ /______ /________ Date Signed Above Technologist Signature Date Signed by Tech ................
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