MRI Patient QuestionnaireMRI 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* Yes NoHave you had prior surgery or an operation?* Yes No(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?* Yes NoMRI, CT, Ultrasound, X-ray, etc.Patient Safety QuestionsAneurysm Clip(s)* Yes NoCardiac Pacemaker* Yes NoImplanted Cardioverter Defibrillator (ICD)* Yes NoSwan-Ganz or Thermodilution Catheter* Yes NoElectronic Implant or Device* Yes NoMagnetically-Activated Implant or Device* Yes NoNeurostimulation system* Yes NoSpinal Cord Stimulator* Yes NoShunt (spinal or intraventricular)* Yes NoInternal Electrodes or Wires* Yes NoBone/Joint Pin, Screw, Nail, Wire, Plate* Yes NoInsulin or other Infusion Pump* Yes NoImplanted Drug Infusion Device* Yes NoHeart Valve Prosthesis* Yes NoArtificial or Prosthetic Limb* Yes NoStent* Yes NoFilter* Yes NoCoil* Yes NoVascular Access Port* Yes NoMedication Patch* Yes NoClaustrophobia* Yes NoHave you ever had metal removed from your eye?* Yes NoTattoo or permanent Makeup* Yes NoBody Piercing Jewlery (remove before entering MR Room)* Yes NoHearing Aid* Yes NoDentures or Partial Plates* Yes NoBone Growith/Bone Fusion Stimulator* Yes NoCochlear, Otologic or other Ear Implant* Yes NoRadiation Seeds or Implant* Yes NoAny Type of Prosthesis (Eye, Penile, etc)* Yes NoEyelid Spring or Wire* Yes NoWire Mesh Implant (hernia)* Yes NoAny metalic fragment or foreign body (bb, bullet)* Yes NoTissue Expander (i.e. Breast)* Yes NoSurgical Staples, Clips, or Metallic Sutures* Yes NoJoint replacement (hip, knee, etc)* Yes NoColonoscopy or Endoscopy in last 6 wks.* Yes NoOther Implants?* No Any surgery in 6 weeks?* Yes NoFor Female PatientAre you pregnant? Yes NoAre you currently breastfeeding? Yes NoIUD, diaphragm, or pessary Yes NoNotesConsent* 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* Patient Relative Nurse HiddenForm Information Reivew ByPrint NameHiddenForm Information Reivew BySignatureHiddenDate MM slash DD slash YYYY HiddenPlease 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?* Yes NoHistory of renal or kidney disease?* Yes NoIncluding: Dialysis, Kidney transplant, Kidney surgery, History of known cancer involving the kidney(s).History of lvier disease?* Yes NoAre you being treated for hypertension (high blood pressure) requiring medical treatment?* Yes NoAre you diabetic?* Yes NoHave you had an adverse reaction or been allergic to MRI contrast media (gadolinium)* Yes NoDid 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?* Yes NoPlease list:Do you have other allergies (medications, food, latest, etc.)?* Yes NoPlease 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 MM slash DD slash YYYY Time : Hours Minutes AMPM AM/PMHiddenTechnologist/nurse has reviewed information on form with patient. HiddenTechnologist/Nurse Full Name HiddenDate MM slash DD slash YYYY HiddenLab HiddenCreatineHiddeneGFRHiddenDate MM slash DD slash YYYY Did you have an injury to the area we are scanning?* Yes NoHow and When?Any pain in the area we are scanning?* Yes NoHow often and Where?Does anything make the pain worse?* Yes NoExplainAny surgery in the area we are scanning?* Yes NoWhen & Where?Any mass in the area we are scanning?* Yes NoDescribeDo you have a personal history of cancer?* Yes NoType & WhenHave you ever had another test of the area that is being scanned today?* Yes NoMRI, CAT scan, X-Ray, Ultrasound, and Nuclear MedicineWhat facility and date:Do you have any other medical conditions?* Yes NoExplainNeurological ExamPlease fill this section out if exam is: Brain, Spine, Orbit, Face, Neck, MRA Head or NeckDo you have any numbness or weakness?* Yes NoDescribeHave you had any bowel or bladder changes?* Yes NoDescribeHave you been diagnosed with MS?* Yes NoDo you have a history of visual problems?* Yes NoDo you have a history of seizures?* Yes NoDate of last seizure:Do you have a history of stroke?* Yes NoDate of last stroke:Do you have a history of dizziness or loss of balance?* Yes No 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
