Newport Diagnostic Center



4051300-342900Newport Diagnostic Center00Newport Diagnostic CenterMRI SAFETY SCREENING QUESTIONNAIREName:Date of Birth:MRN:Today’s Date:Height: Weight:61976088900 00 139700090805Magnetic resonance imaging (MRI) systems use strong magnetic fields and radio-frequency energy for imaging soft tissue in the body. Certain implants, devices, or objects may pose a hazard to individuals in close proximity to the magnet of the MRI system and/or may interfere with the MRI procedure.00Magnetic resonance imaging (MRI) systems use strong magnetic fields and radio-frequency energy for imaging soft tissue in the body. Certain implants, devices, or objects may pose a hazard to individuals in close proximity to the magnet of the MRI system and/or may interfere with the MRI procedure.Do you have any of the following?YESNO??Cardiac pacemaker or implanted cardioverter defibrillator/ICD??Cardiac monitor / loop recorder??Internal electrodes or wires (pacing wires, DBS or VNS wires)??Stents, Stimulators, Pumps, Artificial heart valve, coil, filter and/or stent (ex; IVC filter)??Aneurysm clip(s)??Neurostimulator-TENS Unit, Biostimulator, bone growth stimulator, DBS, VNS??Implanted drug pump (for chemotherapy medicine, pain medicine)??External drug pump / or monitor (for Insulin or other medicine) ??IV access port (Port-a-Cath, Broviac, PICC line, Swan-Gantz, Thermodilution)??Implanted post surgical hardware (pins, rods, screws, plates, wires, coils)??Artificial joint and/or limb??Artificial eye and/or eyelid spring??Eye injury from a metal object (metal shavings, metal slivers)??Ear (Cochlear) implant, middle ear implant??Hearing aid(s)??False teeth/dentures, metallic removable dental work, braces, retainers??Any type of implant held in place by a magnet??Shrapnel, Bullet or BB (Injured by metal object) and required medical attention??Medication patch (Nitroglycerine, nicotine, contraceptive, estrogen)??Shunt or transcutaneous (Sophy) pressure-adjustable and programmable pressure valve??Spinal Fusion, Spinal fixation device and/or halo vest, Spinal Cord Stimulator??Surgical clips, staples or surgical mesh??Tissue expander (breast)??Penile Implant??IUD, Diaphragm??Radiation seeds (cancer treatment), Breast Markers??Body piercing, tattoo or permanent makeup??Wig, hair implants??Any Implants in your body not listed above: _____________________________Female Patients:Are you pregnant? ? Yes ? No Are you breast-feeding? ? Yes ? No If you are still menstruating, please provide the date of your last period ____________________4133850-304800Newport Diagnostic Center00Newport Diagnostic CenterMRI SAFETY SCREENING QUESTIONNAIRE, continuedIf you answered YES to any of the questions on the front page, please discuss any concerns and/or issues you may have, with your MRI Technologist.Instructions for the Patient, Parent, Guardian:We will provide a locker so ALL items you remove may be stored and locked safely during your scan. You may bring the key in the scan room with you.Remove ALL jewelry and ALL body piercing jewelry and ALL hair accessoriesRemove dentures, false teeth, partial dental plates, retainers.Remove hearing aids and eyeglasses.Remove ALL clothing and change into a gown. (under pants/panties can be left on).Lock your clothes and valuables in the locker provided and remove the key.Please use the restroom before your MRI exam.You will receive a pair of earplugs and/or the headphones before your MRI exam begins. Your physician may have requested performance of an MRI examination that requires the use of an intravenous contrast (dye) administration. While contrast administration is generally safe, any medication has the potential for adverse reactions, and some people are at higher risk for such reactions. Do you have a history of:YESNO??Kidney disease??Diabetes??Drug Allergy, type: ___________________??Are you on Dialysis??Allergic reaction to MRI contrastAdverse Reactions:The adverse event rate for GBCM (Gadolinium Based Contrast Media) administered at clinical doses (0.1–0.2 mmol/kg for most GBCM) ranges from 0.07% to 2.4%. Most reactions are mild and physiologic, including coldness, warmth, or pain at the injection site; nausea with or without vomiting; headache; paresthesias; and dizziness. Allergic like reactions are uncommon and vary in frequency from 0.004% to –0.7%. The manifestations of an allergic-like reaction to a GBCM are similar to those of an allergic-like reaction to an iodinated contrast medium. Severe life-threatening anaphylactic reactions occur but are exceedingly rare (0.001% to 0.01%) In an accumulated series of 687,000 doses there were only five severe reactions. In a survey of 20 million administered doses, there were 55 severe reactions. A large single-institution study that included more than 100,000 GBCM injections demonstrated an allergic-like reaction frequency of 0.15%, with 0.13% mild reactions and 0.006% severe reactions (six reactions). Fatal reactions to gadolinium chelate agents occur but are extremely rare.I attest the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and I have had the opportunity to ask questions regarding the information on this form._______________________________________________Patient/Parent/Guardian/Other SignatureDate ................
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