MRI Patient Questionnaire
Patient Name:
Date:
Referring Provider:
Date of Birth:
Weight:
Height:
Personal History
Cardiac Pacemaker – (circle one only please)
Yes
No
If Yes, Medtronic Revo SureScan or Advisa DR MRI SureScan
Bone growth/bone fusion stimulator
Yes
No
Other implant
Yes
No
Implanted cardioverter defibrillator (ICD)
Yes
No
Any metallic fragment or foreign body
Yes
No
Neurostimulation system
Yes
No
Radiation seeds or implants
Yes
No
Aneurysm clip(s)
Yes
No
Internal electrodes or wires
Yes
No
Tissue expander (e.g. breast)
Yes
No
Heart valve prosthesis
Yes
No
Cochlear, otologic, or other ear implants
Yes
No
Joint replacement (e.g. hip, knee)
Yes
No
Metallic stent, filter, or coil
Yes
No
Wire mesh implant
Yes
No
Shunt (spinal or intraventricular)
Yes
No
IUD, diaphragm, or pessary
Yes
No
Any type of prosthesis (eye, penile, etc.)
Yes
No
Artificial or prosthetic limb
Yes
No
Implanted drug infusion device
Yes
No
Tattoo or permanent make-up
Yes
No
Spinal cord stimulator
Yes
No
Breathing problem or motion disorder
Yes
No
Eyelid spring or wire
Yes
No
Are you diabetic?
Yes
No
Pill cam capsule endoscopy device
Yes
No
Body piercing jewelry
Yes
No
Surgical staples, clips, or metallic sutures
Yes
No
Dentures or partial plates
Yes
No
Medication patch (Nicotine, Nitroglycerine)
Yes
No
Are you pregnant?
Yes
No
Bone/joint pin, screw, nail, wire, plate, etc.
Yes
No
Magnetically-activated implant or device; or electronic implant or device
Yes
No
Swan-Ganz or thermodilution catheter or vascular access port and/or catheter
Yes
No
Hearing aids (Remove before entering MRI system room)
Yes
No
Injury to eye by metallic object: if yes – was it removed by a physician? ☐ Yes ☐ No
Yes
No
IMPORTANT INSTRUCTIONS: Before entering the MR environment or MR system room, you must remove all metallic objects including hearing aids,
dentures, partial plates, keys, beepers, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, money
clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clippers, tools, clothing with metal fasteners, & clothing with metallic
threads.
I attest that the above information is correct to the best of my knowledge. I have read and understand
the contents of this form and have had the opportunity to ask questions regarding the MR procedure that I
am about to undergo.
Form Completed By:
Signature:
Relationship to Patient:
Date:
For Staff Use Only:
Reviewed By:
Staff:
MRI Patient Questionnaire 8.24.15
Date:
Staff:
Date:
(719) 785-9000
877-6-PENRAD • (877) 673-6723
PENRAD.org
MRI Patient Questionnaire
Patient Name:
Date:
Reason for examination?
Are your symptoms related to an accident or injury?
Yes
No
Date?
Type of accident or injury:
Is this exam a follow up to a prior injury or medical condition? Yes No (Specify):________________________
Have you had surgery on the body part(s) being scanned today? Yes
No
What procedure was performed?
Date:
Facility:
Provider:
Please list any other known medical conditions:
Do you have a personal history of cancer? Yes
No
Where?
What medications are you currently taking?
Allergy or any reactions to MR contrast (Gadolinium)
Yes
No
Are you allergic to any medications?
Yes
No
Please list:
Are you allergic to LATEX products?
Yes
No
Circle Symptoms as they Apply to your Specific Exam
Body MRI
Difficulty Swallowing
Yes
No
Nausea or Vomiting
Yes
Diarrhea
Yes
No
Constipation
Yes
Jaundice (yellow skin)
Yes
No
Pain
Yes
Brain MRI
Headaches/Pain
Yes
No
Seizures
Yes
Weakness
Yes
No
Hearing Problems
Yes
Visual Problems
Yes
No
Numbness
Yes
Speech Problems
Yes
No
Difficult Walking
Yes
Difficult Thinking
Yes
No
Eye MRI
Which eye is involved?
Right
Left Both Is your vision affected?
Yes
No
Blurred:
Loss Of:
Double Vision:
Pain
Yes
No
IACS or TMJ
Ear
Pain R
L Ringing
R L
Deafness
R L
Pressure R
L
Hearing Loss
R
Teeth Pain R L Grinding R L
Sensitivity R L Clicking
R
L Locking
R
Neck Pain R L Stiffness R L
Musculosketal
Pain
Yes
No
Locking
Yes
No
Swelling
Yes
No
Infection
Yes
No
Mass
Yes
No
Spine MRI
Pain
Back
Neck
Right Leg
Left Leg
Right Arm
Left Arm
Weakness
Back
Neck
Right Leg
Left Leg
Right Arm
Left Arm
Numbness
Back
Neck
Right Leg
Left Leg
Right Arm
Left Arm
No
No
No
No
No
No
No
L
L
Have you had previous radiology studies on the body part(s) being scanned today?
MRI
Location:
MRI
Location:
CT
Location:
CT
Location:
UL
Location:
X-Ray
Location:
MRI Patient Questionnaire 8.24.15
(719) 785-9000
877-6-PENRAD • (877) 673-6723
PENRAD.org