MRI Patient ScreeningForm - Part A
INFORMATION
PATIENT
MRISERVICES
ExamOrdered:
Physician/Specialty:
Diagnosis:
MedicalRecord#:
Zip Code:
Patient's
Dateof Exam:
PatientName:
Dateof Birth:
PatientStatedWeight:
FacilityName:
Reasonfor Exam:
PATIENTHISTORY
MRI CANNOTbe performedif "Yes" is answeredto tripleasterisked(***)questions.
release.Singleasterisked(*) mustbe referredto radiologist.
Doubleasterisked(**) requirea signedcontraindication
* Diabetes
** Pacemakeror Pacemakerwires
tr Yes ONo
O Yes ON o
** SmallBowelEndoscopyCapsule
O Yes DNo
tr Yes ON o
" DiabeticPump
* Wound Dressing(i.e.Acticoat7)
*** lmplantedNeurostimulators
O Yes DNo
tr Yes trN o
* BreastTissue Expanders
*** lmplantedCardiacDefibrillator
tr Yes DNo
tr Yes ON o
** Pregnant/ BreastFeeding
tr Yes ON o
fl Yes trNo
Asthma
* AneurysmClips
O Yes trN o
tr Yes ONo
lrregularHeartbeat
(Ve.ify and document safety o. refer to the radlologist)
O Yes DNo
ExternalElectrodes/Neurostimulators
O
Yes
QN
o
" CarctidClips
(Tens-unit)
* Artificial HeartValves
fl Yes B N o
tr Yes D No
VenaCava UmbrellaFilter
O Yes QN o
" HeartStents
tr Yes tr No
LatexAllergies
lf yes to previoustwo questions need tr Yes ONo
History of Cancer
Make:
Date:
DevicesO Yes ONo
MetalliclmplanUProsthesis/Orthopedic
O Yes trNo
RemovableHearingAid
Model:
tr Yes O No
Epilepsy(Seizures)
* History of severe hepaticdisease/livertransplanUpending
D Yes O No
Uncooperativeor Disoriented
forperloperativo
liv6rpts.) tr Yes tr No Claustrophobia
liver transplant(nocontrast
trYes DNo
* Hypertension
B Yes Q No
tr Yes trNo
Unableto Hold Still
* VascularClips/Grafts/Stents/Repair
tr Yes D No Braces
O Yes ONo
* SurgicalClips
tr Yes O No RemovableDentalWork
tr Yes QNo
* InfusionPump
tr Yes D No Glitter/PermanentEye Makeup
O
Yes DNo
n Programmable
B Yes O No Tattoosand/or Body Piercing
Shunt
Yes D No
O
* Allergiesto lV dye, seafood,shellfish
tr Yes D No MedicationSkin Patches
O Yes flNo
tr Yes O No
" Dialysis/RenalFailure/RenalInsufficiency
(Nitroglycerine,stop smoking, pain, birth control, etc.)
* lron deficiencyor Anemia treatedwith Ferahemetr Yes Q No
* MetallicForeign Body
Any history with a * or ** must be approvedby
tr Yes O No
physician
radiologisUsupervising
ey€,
etc.)
(Gun shot wounds, metal shavlngs In
retinal buckle,
* Prior Ear or BrainSurgery
trYes
Q No
Approved by:
Pleaselist previoussurgeries :
Time:
Date:
Check Box below if a orevious scan completed was
similar to body part being examinedtoday
MRI
Previous
Previous
CT
Previous
PET/PETCT
X-Rays
Previous
QYes
Et Yes
oYes
t rY e s
a No
o No
o No
t rNo
lf yes SpecifyArea
Usingthe figures,pleaseshadein the areas
affectedby pain and/or numbness.
Signatureof Patient:
Date:
(Parentor Guardianif patientis a Minor or Incapacitated)
I have reviewedthis informationwith the patientor their legal guardian,power of aftorney,next of kin' etc.
Tech'sSignature:
RevisedJanuary1,2010
Date:
AttachmentA007
MRI Patient ScreeningForm - Part B
Date:
Dateof Birth:
Patient Name:
\6ur physiaianor radiologist may deem it necessaryfor you to have an lV injection of a contrast agent containing
gadoliniumto improvethe quatityof your MR examination.Althoughgadoliniumcontrastagentshave been used
safelyin millionsof patients,minor reactions(principallyheadacheor nausea),and seriousor life threatening
reactions may occur.
ContrastName
I have read and understandthe above information,and have had my questions
Amount
answered.I agree to have the MRI procedurewith injection of contrast if
deemed necessary.
Lot #
Historyof previousreaction EYes o No
Exp.Date
lf Yes,Explain
InjectionSite
PatientStatedWeight
DeviceUsed
(Range:Low= 30 High= > 60)
eGFR
Rateof Admin.
Techlnitials
X5;"m"*;aam
Haspatient's
condition
changedsinceinjection?No
PostInjection
Check: Time:_
lf Yes,specifychange:
Are you'allergic
to any medications,
seafood.or shellfish?
o Yes tr No
lf Yes,pleaselist:
Barriersto Learninq
Type:
tr Language
tr Hearing
tr Other
Yes_
tr Yes
O No
lntervention:
tr InterpreterUsed
tr RepeatQuestions
D Family/Significant
Other
E Patientunawareof currentmedications
tr Patientnot on any medications
List anv medication(s}the patienthas takentoday and all current medications:
(lncludeover the counter,ointments,herbals,vitamins,birth control,etc,)
Y
10
Prior to release,patientwas assessedand found impaired? O Yes tr No lf yes, SupervisingPhysiciannotified? O Yes tr No
lf patient refusesfurther assessment,notify SupervisingPhysicianand Alliance personnelto follow policy #5023.
Commentsr
MINORMODIFICATIONS
BY RADIOLOGIST/PHYSICIAN
tr Yes tr No
OriginalExamOrderGhangedto:
TechSignature:
Ghangedby:
Date/Time:
ReadBack Q Yes tr No PhysicianSignature:
Post InjectionInstructionsgiven (applicableto all patientswho receivean injection).
Patientnotified of rights and opportunity to "Speak up" with questions or concerns.
Handoff Report given to next provider of care. Medicationlist provided if applicable.
D Yes
fl Yes
I Yes
I tto
fl tto
fl lr|o
lnterviewerSignature
Title:
Date:
TechComments
RevisedJanuarv1. 2010
AttachmentA00T