Get Mri Screening Form

MRI Patient History and Screening Form Patient Name Weight Date D. O. B Age Sex M F Referring Physician Allergies Reason you are here today Explain your medical problem in detail such as What and where is the problem and how long have you had it Yes No Is your problem injury related. Injury Date How Injured MVA Work Other Yes No Have you had a previous exam related to this problem If Yes explain If yes Do you have someone to drive you home Yes No Do you have or have you ever had any of the following Yes No Shunts/Stents/Intravascular Coil Yes No Eye Surgery/Implants Yes No Orthopedic pins screws rods Harrington Rod etc. Yes No Neurostimulator/Biostimulator Implanted cardiac defibrillator Yes No Radiation Therapy/Chemo Therapy Yes No Vascular Access Port Yes No Metal Mesh Implants/Wire sutures/wire staples/internal electrode Yes No Implanted drug infusion pump/ pump Yes No Tattoo s/Permanent make-up/Body Piercing Yes No Dentures partials or dental implants Yes No Gunshot Wounds shrapnel BB s Yes No Nicotine or any other patch Yes No Do you have pins in hair hair extensions hair pieces or a wig Yes No Any electrical mechanical or magnetic implants. Type Yes No Previous Back Surgery Low Back or Cervical When Levels Yes No History of Cancer or Tumors When Where Yes No Injury to the eye involving metal or metal shavings. Orbits reviewed by OR have you ever worked as metal grinder welder or in a foundry Yes No Heart Surgery/Heart Valve/Pacemaker/Pacemaker wires. If yes explain Yes No Brain Surgery/Brain Aneurysm Clips. If yes explain List previous Surgeries MRI Contrast History Yes No Have you ever had MRI contrast If yes explain Yes No Is there a possibility of pregnancy Yes No Are you breast feeding Not applicable to this exam If Yes did you have any kind of reaction Yes No LMP if applicable C Documents and Settings Deb Local Settings Temporary Internet Files Content. Type Yes No Previous Back Surgery Low Back or Cervical When Levels Yes No History of Cancer or Tumors When Where Yes No Injury to the eye involving metal or metal shavings. Orbits reviewed by OR have you ever worked as metal grinder welder or in a foundry Yes No Heart Surgery/Heart Valve/Pacemaker/Pacemaker wires. Orbits reviewed by OR have you ever worked as metal grinder welder or in a foundry Yes No Heart Surgery/Heart Valve/Pacemaker/Pacemaker wires. If yes explain Yes No Brain Surgery/Brain Aneurysm Clips. If yes explain List previous Surgeries MRI Contrast History Yes No Have you ever had MRI contrast If yes explain Yes No Is there a possibility of pregnancy Yes No Are you breast feeding Not applicable to this exam If Yes did you have any kind of reaction Yes No LMP if applicable C Documents and Settings Deb Local Settings Temporary Internet Files Content. Type Yes No Previous Back Surgery Low Back or Cervical When Levels Yes No History of Cancer or Tumors When Where Yes No Injury to the eye involving metal or metal shavings. Orbits reviewed by OR have you ever worked as metal grinder welder or in a foundry Yes No Heart Surgery/Heart Valve/Pacemaker/Pacemaker wires. If yes explain Yes No Brain Surgery/Brain Aneurysm Clips. If yes explain List previous Surgeries MRI Contrast History Yes No Have you ever had MRI contrast If yes explain Yes No Is there a possibility of pregnancy Yes No Are you breast feeding Not applicable to this exam If Yes did you have any kind of reaction Yes No LMP if applicable C Documents and Settings Deb Local Settings Temporary Internet Files Content.