MRI History and Consent Form
Patients Name: _______________________________Date of Exam: ___________
DOB: ______________ Age: ________ Weight: _______ Height: ________
Male or Female If Female, Last Menstrual Period : ______________ Postmenopausal: Yes or No
Referring Doctor : ___________________________ Doctor Phone #:_______________________
Reason for MRI: ________________Body Part to be Examined: ___________Medical Record #: ________
These Items Can Interfere With MR Imaging And Some Can Be Hazardous To Your Safety.
Please Check All That Apply
____ An injury to your eye involving metal?
____ A metallic fragment or foreign body in your hand,
face, neck, or body?
____ If yes to either question above, were you tested
to ensure all was removed? Yes or No
____ Cardiac Pacemaker
____ Pacemaker Wires
____ Electronic Implant or Device
____ Spinal Cord Stimulator
____ Cochlear, Otologic or Ear Implant
____ Internal Electrodes or Wires
____ Cardiac Stent
____ Artifical Heart Valve
____ Endoscopy Camera Pill
____ Coil, Filter, Wire in Blood Vessel
____ Stent In Blood Vessel
____ Shunt (spinal or intraventricular)
____ Prosthesis (eye, penile, etc.)
____ Radiation Seeds or Implants
____ Artificial Limb/ Joint Replacement
____ Tens Unit
____ Vascular Access Port/ Catheter
____ IUD or Diaphram
____ Body Piercing Jewelry
____ Motion Disorder
____ Aneurysm Clip
____ Neurostimulator
____ Implanted Cardiac Defibrilator
____ Bone Fusion or Bone Growth Stimulator
____ Tissue Expander (e.g. breast)
____ Magnetically Activated Implant or Device
____ Swan-Ganz or Thermodiluton Catheter
____ Clips in Blood Vessel
____ Implanted Drug Infusion Device/Pump
____ Venous Umbrella
____ Pessary or Bladder Ring
____ Any Metallic Fragment of Foreign Body
____ Transdermal Medication Patch (Nitro, Nicotine)
____ Bone/Joint Pin, Screw, Nail, Wire, Plate, etc
____ Harrington Rod (Spine)
____ Wire mesh Implant
____ Surgical Staples, Clips or Metallic Sutures
____ Tattoo or Permanent makeup
____ Dentures or Partial Plates
____ Hearing Aid (Remove Before exam)
____ Claustrophobia
Hearing Protection Must Be Worn During Exam
Earplugs Will Be Provided
Contrast Consent
Due to your medical history, or as requested by your physician, an injection or MRI Gadolinium Contrast may be necessary to
aid the radiologist in evaluating your MRI scan. The Food and Drug Administration has approved this agent. A very small
percentage of patients receiving Gadolinium may develop a headache or experience mild nausea. Rarely, local inflammation
may occur at the injection site.
DO YOU HAVE:
YES
NO
Technologist Notes
________________________________________________________
________________________________________________________
________________________________________________________
Kidney problems ………………………………………...
Liver Problems …………………………………………….
Asthma or a Respiratory Disease………….
Diabetes………………………………………………………..
Have you ever had an allergic reaction to MRI contrast?
YES
NO
List all known allergies: __________________________________________________________________________________
I Consent to having Gadolinium contrast as needed.
I Decline Gadolinium contrast at this time. (check appropriate box)
Patient/Guardian Signature: ___________________________ Technologist Signature: ______________________
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Do Not Enter the MR system room or MR environment if you have any question or concern regarding
an implant, device, or object. Consult the MRI Technologist BEFORE entering the MRI exam room.
The MR system is always on.
It is recommended to discontinue breast feeding and discard breast milk for 48 hours after Gadolinium
injections. Are you: Pregnant? YES NO Possibly Pregnant? YES NO Breast Feeding? YES NO
MRI Radiofrequency has the potential to cause tissue heating. The Technologist will take several
precautions to avoid this. Alert the Technologist immediately if you notice any heating sensations during
your MRI scan.
A small number of patients with tattoos have experienced transient skin irritation, swelling, or heating
sensations at the site of the permanent colorings in association with MR procedures. Individuals with
tattoos or permanent makeup should inform the technologist so appropriate precautions can be taken.
Did you injure the area of interest?___ If yes, describe: ______________________________________
Have you had another exam of the area we are scanning? ___ If yes, describe what/when/where?
___________________________________________________________________________________
Have you had surgery or radiation therapy on the area we are scanning? ____ If yes, describe:
__________________________________________________________________________________
ABDOMEN
___Abdominal Pain (describe)
___Sharp___Dull___Aching___Burning
___Difficulty Swallowing
___Loss of Appetite
___Nausea / Vomiting
___Bowel or Bladder Changes
___Weight Loss or Gain
HIP / LEG / KNEE / ANKLE / FOOT
___Right
___Left
___Locking
___Giving Away
___Numbness
___Lump or Mass
___Pain (describe)
___Sharp___Dull___Aching___Burning
NECK
___Lump or Mass
___Difficulty Swallowing
___Diffculty Talking
___Pain
___Sore Throat
CHECK ALL SYMPTOMS RELATED
TO THE TYPE OF MRI SCAN YOU
ARE HAVING TODAY
BRAIN /IAC
___Headaches
___Seizures
___Dizziness
___Speech Problem/Trouble Talking
___Hearing Problem ___Right ___Left
___Visual Problem ___Right ___Left
ARM /SHOULDER /ELBOW / WRIST /
HAND
___Right
___Left
___Limited Range of Motion
___Numbness
___Weakness
___Popping
___Grinding
___Swelling
___Lump or Mass
___Pain (describe)
___Sharp___Dull___Aching___Burning
FEMALE PELVIS
___Irregular Menstruation
___Painful Menstrual Cycles
___Painful Intercourse
___Hysterectomy
___Ovaries Removed
SPINE Cervical / Thoracic / Lumbar
___Back Pain (describe)
___Upper___Middle___Lower
___Dull___Sharp___Both
___Neck Pain (describe)
___Dull___Sharp___Both
___Weakness In:
___R Arm___L Arm___R Leg___L Leg
___Pain In:
___R Arm___L Arm___R Leg___L Leg
___Numbness In:
___R Arm___L Arm___R Leg___L Leg
CHEST
___Difficulty Breathing
___Chest Tightness / Chest Pain
___Moist Cough ___Dry Cough
___Heart Disease
I attest that the information on this form is correct to the best of my knowledge. I have read and understand the contents of
this form and had the opportunity to ask questions regarding the MR procedure I am about to undergo.
Patient/Guardian Signature: ________________________________________ Today’s Date: ___________________
Staff Signature: ______________________________Print Name: _____________________________ Tech / Nurse/ Radiologist