MRI Patient Questionnaire MRI Patient QuestionnaireStep 1 of 333%Warning: Certain implants, devices or object may be hazardous to you and or may interfere with the Magnetic Resonance (MR) procedure (i.e., MR, MR Angiography, Functional MRI, and MR Spectroscopy). Do Not Enter the MRI system room or MR environment if you have any question or concern regarding an implant, device or object. Consult with the MRI Technologist or Radiologist before entering the MRI system room. The MR System Magnet Is Always On. Note: You will be required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems or hazards related to acoustic noise. Please consult with the MRI Technologist or Radiologist if you have any questions.Patient InformationPatient Name* First Last Emergency Contact Name* First Last Relationship to Patient*Phone*Assisted Needed*YesNoHave you had prior surgery or an operation?*YesNo(e.g. brain, eye, heart, ear)If yes, please indicate the date and type of surgery.Have you had a prior diagnostic imaging study or examination?*YesNoMRI, CT, Ultrasound, X-ray, etc.Patient Safety QuestionsAneurysm Clip(s)*YesNoCardiac Pacemaker*YesNoImplanted Cardioverter Defibrillator (ICD)*YesNoSwan-Ganz or Thermodilution Catheter*YesNoElectronic Implant or Device*YesNoMagnetically-Activated Implant or Device*YesNoNeurostimulation system*YesNoSpinal Cord Stimulator*YesNoShunt (spinal or intraventricular)*YesNoInternal Electrodes or Wires*YesNoBone/Joint Pin, Screw, Nail, Wire, Plate*YesNoInsulin or other Infusion Pump*YesNoImplanted Drug Infusion Device*YesNoHeart Valve Prosthesis*YesNoArtificial or Prosthetic Limb*YesNoStent*YesNoFilter*YesNoCoil*YesNoVascular Access Port*YesNoMedication Patch*YesNoClaustrophobia*YesNoHave you ever had metal removed from your eye?*YesNoTattoo or permanent Makeup*YesNoBody Piercing Jewlery (remove before entering MR Room)*YesNoHearing Aid*YesNoDentures or Partial Plates*YesNoBone Growith/Bone Fusion Stimulator*YesNoCochlear, Otologic or other Ear Implant*YesNoRadiation Seeds or Implant*YesNoAny Type of Prosthesis (Eye, Penile, etc)*YesNoEyelid Spring or Wire*YesNoWire Mesh Implant (hernia)*YesNoAny metalic fragment or foreign body (bb, bullet)*YesNoTissue Expander (i.e. Breast)*YesNoSurgical Staples, Clips, or Metallic Sutures*YesNoJoint replacement (hip, knee, etc)*YesNoColonoscopy or Endoscopy in last 6 wks.*YesNoOther Implants?*NoAny surgery in 6 weeks?*YesNoFor Female PatientAre you pregnant?YesNoAre you currently breastfeeding?YesNoIUD, diaphragm, or pessaryYesNoNotesConsent* I agree....I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form. I had the opportunity to ask questions regarding the information on this form and the MR procedure that I am about to undergo.Please check*PatientRelativeNurseForm Information Reivew ByPrint NameForm Information Reivew BySignatureDate Date Format: MM slash DD slash YYYY Please check MRI Technologist NurseWill you be having a Contrast Study?* Yes NoConsent for Contrast MaterialPatient Name* First Date of Birth*Weight*Consent*Your physician has ordered a diagnostic exam that requires an injection of intravenous contrast media or "dye". This procedure has been ordered to help your physician understand and treat your medical condition. We cannot administer any type of contrast media without your permission. We routinely request Lab results to screen for renal insufficiency. Warning: Certain implants, devices or object may be hazardous to you and or may interfere with the Magnetic Resonance (MR) procedure (i.e., MR, MR Angiography, Functional MRI, and MR Spectroscopy). Do Not Enter the MRI system room or MR environment if you have any question or concern regarding an implant, device or object. Consult with the MRI Technologist or Radiologist before entering the MRI system room. The MR System Magnet Is Always On. Note: You will be required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems or hazards related to acoustic noise. Please consult with the MRI Technologist or Radiologist if you have any questions. MRI Exams: The amount of contrast media is administered according to your body weight. You will be exposed to a strong magnetic field and radio impulses during this test. MRI has not been FDA approved for pregnant women although, to date, there has been no indication of harmful effects during pregnancy. Please inform the technologist if there is a possibility of pregnancy or if you are breast feeding. Risks: Any type of injection carries a slight risk of injury to soft tissue, nerves, arteries, veins or kidneys. Infection and reaction can also occur. Side effects ranging from mild to moderate include itching, hives, nausea and/or vomiting. Severe complications are extremely rare, but do sometimes occur. This complication results in anaphylaxis or shock, and can be potentially life-threatening. I consent to the administration of emergency medication to me in the event of a contrast reaction.*Contrast Exams Only (select all that apply)Are you 60 years or older?*YesNoHistory of renal or kidney disease?*YesNoIncluding: Dialysis, Kidney transplant, Kidney surgery, History of known cancer involving the kidney(s).History of lvier disease?*YesNoAre you being treated for hypertension (high blood pressure) requiring medical treatment?*YesNoAre you diabetic?*YesNoHave you had an adverse reaction or been allergic to MRI contrast media (gadolinium)*YesNoDid you take allergy prep medication for this exam?* Prednisone Solucortef Benadryl None OtherDescribeTime of last dose:Have you been injected with an IV contrast dye for another exame in the last week?*YesNoPlease list:Do you have other allergies (medications, food, latest, etc.)?*YesNoPlease list:Consent*I have read the above information, answered the questions and have had ample opportunities to ask questions about the nature of this procedure and the risks, alternatives and benefits. I understand that at any time I may request the test to be discontinued. I agree/consent to the administration of Intravenous Contrast Material.*Parent or Guardian (relationship) Full Name Date Date Format: MM slash DD slash YYYY Time : HH MM AMPM Technologist/nurse has reviewed information on form with patient. Technologist/Nurse Full Name Date Date Format: MM slash DD slash YYYY Lab CreatineeGFRDate Date Format: MM slash DD slash YYYY Did you have an injury to the area we are scanning?*YesNoHow and When?Any pain in the area we are scanning?*YesNoHow often and Where?Does anything make the pain worse?*YesNoExplainAny surgery in the area we are scanning?*YesNoWhen & Where?Any mass in the area we are scanning?*YesNoDescribeDo you have a personal history of cancer?*YesNoType & WhenHave you ever had another test of the area that is being scanned today?*YesNoMRI, CAT scan, X-Ray, Ultrasound, and Nuclear MedicineWhat facility and date:Do you have any other medical conditions?*YesNoExplainNeurological ExamPlease fill this section out if exam is: Brain, Spine, Orbit, Face, Neck, MRA Head or NeckDo you have any numbness or weakness?*YesNoDescribeHave you had any bowel or bladder changes?*YesNoDescribeHave you been diagnosed with MS?*YesNoDo you have a history of visual problems?*YesNoDo you have a history of seizures?*YesNoDate of last seizure:Do you have a history of stroke?*YesNoDate of last stroke:Do you have a history of dizziness or loss of balance?*YesNo Schedule an AppointmentCall our office or fill out the form below, and we will contact you within 48 hours to confirm your appointment.Call: 989-773-2081 | Fax: 989-773-3418 Fill Out Form
