CPC Diagnostic Center
Today’s date:
Name:
Account #_________
Height
DOB:
Weight
Circle or underline MRI risk considerations:
1. Heart valve, pacemaker, or defibrillator
2. Brain aneurysm clip or coils
3. Stents
4. Eye implants
5. Neurostimulator
6. Cochlear implant
7. Vascular access port
8. Metal mesh, wire sutures, staples, internal electrode
9. Infusion drug pump
10. Tattoo’s or body piercing
11. Dentures
12. gunshot wounds or BB’s
13. hair extensions, wig, or hair piece
14. Safety pins in your clothes
What are your symptoms related to this exam or why are you having this? ___________
________________________________________________________________________
Have you had an operation in the body part that we are going to scan today? If so, when
and what was done? ______________________________________________________
_______________________________________________________________________
You do not need to answer these if you are not getting MRI contrast (gadolinium) today:
Have you had gadolinium before? __________ If so, did you have a reaction? _________
________________________________________________________________________
Do you have any kidney function problems?____________________________________
________________________________________________________________________
Severe chronic kidney disease (GFR glomerular filtration rate< 30), or recently
worsening kidney function (falling GFR) & gadolinium administration is associated with
an increased incidence of NSF (nephrogenicsystemic fibrosis). This is hardening of the
skin and other organs.
Mild chronic kidney disease is GFR 60-90 for more than 3 months
Patient signature ______________________________________
Technologist signature _________________________________