MRI Questionaire

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more than just x-rays
MRI QUESTIONAIRE
NAME (L, F):_______________________________ MR#_______________ REFERRING DR: _________________ CC: __________
WT: __________HT:_______ SEX: M __ F __
DOB: ___________ AGE: ______ [email protected]:_____________
EXAM TYPE: _____________________________________ PRIOR SURG TO REGION:
YES
NO
REASON FOR EXAM/SYMPTOMS: ____________________________________________________________________________
Prior MRI of same area?
Prior CT of same area?
Prior XRay of same area?
Ever diagnosed with Cancer?
Previous Radiation Therapy?
Previous Chemotherapy?
Yes
Yes
Yes
Yes
Yes
Yes
☐ No ☐
☐ No ☐
☐ No ☐
☐ No ☐
☐ No ☐
☐ No ☐
Where: ____________________________________
Where: ____________________________________
Where: ____________________________________
Type: _____________________________________
When: ____________________________________
When: _____________________________________
Any history of kidney disease or renal failure?
Yes ☐ No ☐
Is Patient Diabetic?
Yes ☐ No ☐
Is Patient Hypertensive?
Yes ☐ No ☐
Any Surg in past 8 weeks?
Yes ☐ No ☐
Have you ever had head, neck, or brain surgery?
Yes ☐ No ☐
Specify: _______________________________________________________________________________________
Are you pregnant?
Yes ☐ No ☐
Are you Breastfeeding?
Yes ☐ No ☐
Are you Claustrophobic?
Yes ☐ No ☐
Have you ever had an injury to your eyes involving metallic slivers or shavings?
Yes ☐ No ☐
Please indicate if you have any of the following:
Cardiac Pacemaker
Heart Valve Prosthesis
Aneurysm Clip
Eye Implant
Implanted Defibrillator
Implanted Drug Infusion Device
Implanted Electrical or Mechanical Device
Hearing Aid
Cochlear Implant
Joint Replacement
Removable Bridgework or Dentures
Swan-Ganz Catheter
Vascular Stents or Filters:
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
Yes ☐ No
☐ (INFORM STAFF NOW)
☐
☐
☐
☐
☐
☐
Type: __________________________
☐
(REMOVE BEFORE ENTERING MR ROOM)
☐
☐
TYPE: _________ WHEN: ______________
☐
☐
☐
TYPE: __________WHEN:_____________
I CERTIFY THAT I HAVE DOUBLE CHECKED MY POCKETS AND HAVE LEFT ALL PERSONAL ITEMS IN THE
LOCKER. SMDI IS NOT RESPONSIBLE FOR ANY ITEMS LEFT ON MY PERSON. I CERTIFY THAT ALL THE
INFORMATION LISTED ABOVE IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE. I CONSENT
TO THE ADMINISTRATION OF THE ABOVE DIAGNOSTIC TEST(S).
Patient Signature: ___________________________________________Date:_______________
Tech/Comments: _____________________________________________ Date:________ Magnevist cc:__________ Inj Site:_______
www.smdi.net
8303 S. Suncoast Blvd • Homosassa, FL 34446
Phone (352)628-9900 • Fax (352)628-9700
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