DRCTC MRI Screening Form

Diagnostic Radiology Center of the Treasure Coast

MAGNETIC RESONANCE (MR) PROCEDURE
PATIENT SCREENING FORM

NAME

Age

Height

Weight

D.O.B

Male Female

Body part to be imaged today:

The MR system has a very strong magnet field that may be hazardous to individuals entering the MR environment or MR system room if they have certain metallic, electronic, magnetic or mechanical implants, devices or objects. Therefore, all individuals are required to fill out this form BEFORE entering the MR environment or MR system room.

BE ADVISED, THE MR SYSTEM MAGNET IS ALWAYS ON.

1. Do you have a cardiac pacemaker?

Yes No

2. Do you have any metal in your body?

Yes No

3. Do you have an electronic implant or device?

Yes No

4. Do you have a history of cancer?

Yes No

If yes, please describe:

5. Have you had an injury to the eye involving a metallic object or fragment?

Yes No

If yes, please describe:

6. Do you have a history of asthma, allergic reaction, respiratory disease, or reaction to a medium or dye used for an MRI, CT, or X-ray exam?

Yes No

If yes, please describe:

7. Do you have anemia or any disease that affect your blood, a history of renal (kidney)disease, or seizures?

Yes No

If yes, please describe:

8. Are you pregnant or experiencing a late menstrual period?

Yes No

9. Are you currently breastfeeding?

Yes No

10. What health concerns/problems brought you to this office today (please describe)?

11. Do you have any secondary or other complaints?

12. When did you first experience this problem or these problems?

13. Describe how they began or occurred:

14. Does your current pain remain localized or does it radiate (travel to other locations)?

15. What tests have you had to evaluate your current complaints? (Mark all that apply):

X-Rays

Myelogram

MRI

CAT Scan

Bone Scan

Tomogram

I have had no diagnostic tests as those listed above to evaluate my current episode of complaint.

16. Where were the above tests performed and When?

17. List any surgeries you have had (include type of surgery, date and physician or facility):

18. Have you been involved in an auto accident?

Past year Past 5 yrs Over 5 yrs ago Never

Describe :

19. Have you had any other personal injury to area of complaint?

Past year Past 5 yrs Over 5 yrs ago Never

Describe :

Please indicate if you have any of the following:

Aneurysm Clip(s)

Yes No

Vascular Access Port and/or Catheter

Yes No

Cardiac Pacemaker

Yes No

Radiation Seeds or Implants

Yes No

Tattoo or Permanent Makeup

Yes No

Any Metallic Fragment or Foreign Body

Yes No

Electronic Implant or Device

Yes No

Wire Mesh Implant

Yes No

Neurostimulation System

Yes No

Breathing Problem or Motion Disorder

Yes No

Spinal Cord Stimulator

Yes No

Joint Replacement (Hip, Knee, etc.)

Yes No

Tissue Expander (e.g. Breast)

Yes No

Surgical Staples, Clips or Metallic Sutures

Yes No

(IUD), Diaphragm, or Pessary

Yes No

Dentures or Partial Plates

Yes No

Internal Electrodes or Wires

Yes No

Bone Growth / Bone Fusion Stimulator

Yes No

Body Piercing Jewelry

Yes No

Medication Patch (Nicotine, Nitroglycerine)

Yes No

Other Implant

Yes No

Insulin or Other Infusion Pump

Yes No

Implanted Drug Infusion Device

Yes No

Any Type of Prosthesis (eye, penile, etc.)

Yes No

Heart Valve Prosthesis

Yes No

Magnetically Activated Implant or Device

Yes No

Artificial or Prosthetic Limb

Yes No

Metallic Stent, Filter or Coil

Yes No

Shunt (Spinal or Intraventricular)

Yes No

Implanted Cardioverter Defibrillator (lCD)

Yes No

Eyelid Spring or Wire

Yes No

Swan-Ganz or Thermo dilution Catheter

Yes No

Claustrophobia

Yes No

Bone/Joint Pin, Screw, Nail, Wire, Plate, etc

Yes No

Hearing Aid

Yes No

Cochlear, Otologic, or Other Ear Implant

Yes No

I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to undergo.

Information Concerning Gadolinium Contrast Material

As part of your examination, the radiologist may deem it advisable to give you an IV. Injection of a contrast agent containing gadolinium. This injection may help the physician more accurately diagnose your condition. Although gadolinium contrast agents have been safely used in millions of cases, minor reactions (principally headache or nausea) occur in about 2% of patients, whereas serious or life threatening reactions have been reported in about I in 400,000 patients.

Have you ever had a previous allergic reaction to gadolinium contrast material?

Yes No

Do you have a history of asthma or emphysema?

Yes No

CONTRAST TYPE:

AMOUNT:

CC’S

IV SITE:

NEEDLE GAUGE USED

I accept to above all terms and condition

PORT ST. LUCIE FACILITY

FORT PIERCE FACILITY

Diagnostic Radiology Center of the Treasure Coast

MAGNETIC RESONANCE (MR) PROCEDURE PATIENT SCREENING FORM

BE ADVISED, THE MR SYSTEM MAGNET IS ALWAYS ON.

FOR FEMALE PATIENTS

Information Concerning Gadolinium Contrast Material

MAGNETIC RESONANCE (MR) PROCEDURE
PATIENT SCREENING FORM