Longview Radiologists, P
Longview Radiologists, P.S. Inc.
700 Lincoln St. Suite 100, Kelso, WA. 98626
PATIENT NAME__________________________________________________
PROCEDURE____________________________________________________
|YES | |NO | |
| | | |CARDIAC PACEMAKER |
| | | |ANEURYSM / METAL CLIPS FROM BRAIN SURGERY |
| | | |DO YOU HAVE ANY STENTS OR INTRAVENOUS FILTERS? |
| | | |HAVE YOU EVER HAD ANY HEART OR BRAIN SURGERY? |
| | | | A. If yes, please explain. ___________________________________________________ | |
| | | |DO YOU HAVE ANY INTERNAL OR EXTERNAL PAIN PUMPS / INSULIN PUMP? |
| | | |HAVE YOU EVER HAD METAL FRAGMENTS DETECTED IN YOUR EYES? |
| | | |HAVE YOU EVER PERFORMED WELDING OR GRINDING? |
| | | | A. If yes, did you wear eye protection 100 % of the time? |
| | | |METAL IN BODY (from surgeries, shrapnel from wartime activity or gunshot wound) |
| | | |HAVE YOU EVER HAD SURGERY ON THE BODY PART BEING SCANNED? |
| | | |IF YES, WHAT FACILITYAND WHEN?___________________________________________ |
| | | |HEARING AID |
| | | |REMOVABLE DENTURES OR ORAL APPLIANCES |
| | | |OTHER METAL IMPLANTS (please explain) ______________________________________ |
| | | |HAVE YOU BEEN DIAGNOSED WITH CANCER |
| | | | A. If so, what type of cancer?_________________________________________________ |
| | | |ARE YOU PREGNANT? |
| | | |ARE YOU CURRENTLY NURSING? |
| | | |DO YOU HAVE AN IUD IMPLANT? IF YES, WHAT TYPE____________________________ |
| | | |DO YOU HAVE ANY PERMANENT TATTOOS OR PERMANENT EYELINER? |
| | | |ARE YOU CLAUSTROPHOBIC? |
Weight _______
SIGNATURE of patient or representative_____________________________________________________
RELATIONSHIP to patient_________________________________________________________________
Date____________________________________ Time_______________________________________
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THE FOLLOWING ITEMS CAN INTERFERE WITH MRI IMAGING AND SOME MAY BE HAZARDOUS TO YOUR SAFETY.
PLEASE READ CAREFULLY.
TECHNOLOGIST USE ONLY HISTORY:
Tech initials_________________
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