SPRING HILL IMAGING CENTER
MRI PATIENT ASSESSMENT AND SCREENING FORM
Name: ______________________________________________
Birth Date: ________________________________
Reason for Exam: _____________________________________________________________________________________
Weight: ____________
Allergies: __________________________________________________________
List of any Surgeries: ____________________________________________________________________
MRI CANNOT BE PERFORMED IF “YES” IS ANSWERED TO DOUBLE ASTERISKED(**) QUESTIONS.
ALL “YES” SINGLE ASTERISKED (*) ARE TO BE REFERRED TO THE RADIOLOGIST.
________________________________________________________________________________________________________
Do You Have?
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
** Pacemaker, Defibrillator and/or Pacer Wires
** Aneurysm Clip or Brain Surgery
*Neurostimulator (Tens Unit)
* Implanted Electrodes, Pumps, or Electrical Devices
* Metallic Foreign Body
(Gun Shot Wound or Metal Shavings in Eyes)
* Prior Ear, Eye or Brain Surgery
* Pregnant or Nursing an Infant
* Shunt (Spinal or Intraventricular)
Any Type Prosthesis (Eye, Extremity, Penile, Etc.)
Permanent Eyeliner, Tattoos, Body Piercings
Transdermal/Skin/EKG or Medication Patches
Tissue Expander (i.e. Breast, etc.)
Please Answer the Following:
[ ] Yes
[ ] Yes
[ ] No
[ ] No
Do You Have Sickle Cell Anemia?
Do You Have Kidney Disease?
(i.e. Kidney,Dialysis, Transplanted Kidney, etc.)
[ ] Yes
[ ] No
Current or Past History of Cancer?
If Yes, Please List: ____________________________
Any Previous MRI/CT Scans:
If Yes Explain: ______________________________
[ ] Yes
[ ] No
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
Prosthetic Heart Valve
Other Heart Surgery or Stents
Hearing Aid or Dentures
Orthopedic (bone) Device
Hearing Aid or Dentures
Prior Vascular Surgery
Joint or Limb Replacement
Metal Rod, Pin, Screw or other
Orthopedic (bone) Device
TO BE COMPLETED BY STAFF:
Date of Lab Results: _________________
Creatinine: _____________
Performed by I Stat? [ ] Yes [ ] No
GFR (calculated): _______________
[ ] Yes
[ ] Yes
[ ] Yes
[ ] No
[ ] No
[ ] No
Do You Have Liver Disease?
Do You Have High Blood Pressure
Do You Have Diabetes?
-You will be asked to remove all metallic objects
before entering into the Magnet room. This will
include jewelry, keys, beepers, cell phones, coins,
watches, hair pins, wallet, pocket knife, etc) A
locker will be provided if you choose not to leave
with a family member.
_________ _______ _______ ______ _______ _______ ______ _______ _______ ______ _______ ______ _______ _______ ______ ______
CONTRAST:
Your physician or radiologist may deem it necessary for you to have an IV injection of a contrast liquid containing gadolinium to improve the quality of your MRI
examination. Although gadolinium contrast agents have been used safely in millions of patients, minor reactions (principally headache or nausea) occur in 2% of
patients, and serious or life threatening reactions have been reported in 1 in 400,000 patients. I have read and understand the above information, and have had
my questions answered. I request that the MRI procedure be performed, including the injection of contrast if deemed necessary by my physician or the radiologist
performing the MRI procedure.
Signature of Patient (Parent or Guardian) _____________________________________________ Date: __________________
To the best of my knowledge the above information is correct: ________________________________________________ Date: ____________
[ ] Yes
[ ] No
History of Previous Reaction
[ ] Omniscan
[ ] Magnevist
[____] ml’s Used
If Yes Explain: __________________________________
IV Access: ______ Gauge: ________ Site [ ] Pre-existing
[ ] Yes
New IV Site by: ____________________________________
[ ] No
Asthma or Emphysema
MRI Technologist: ________________________________________
Current Medications: ______________________________________________________________________________________________________