Breast Mri Questionnaire (Page 2 of 2) in pdf

Patient Name: _____________________________________

Date of Birth: ____________

□ Yes □ No

Have you ever had an operation of any kind to the area being scanned today?

If so, please list them all with dates.

______________________________________________________________

□ Yes □ No

Have you ever been a machinist, welder, or metalworker?

□ Yes □ No

Have you ever had a piece of metal in your face or eyes? This includes metal

shavings, slivers, bullets, and BBs.

□ Yes □ No

Are you pregnant, possibly pregnant, or breastfeeding?

Do you have any of these items in your body?

TO OUR PATIENTS AND ACCOMPANYING

□ Yes □ No

Pacemaker, wires, or defibrillator

FAMILY MEMBERS:

□ Yes □ No

Brain aneurysm clip

The MRI room contains a very strong

□ Yes □ No

Carotid artery vascular clamp

magnet. Before you are allowed to enter, we

□ Yes □ No

Ear implant or hearing aids

must know if you have any metal in your

□ Yes □ No

Eye implant

body. Some metal objects can interfere with

□ Yes □ No

Bullets, BBs, shrapnel, or pellets

your scan or may even be dangerous, so

□ Yes □ No

Magnetic implant

PLEASE answer all the questions carefully. If

□ Yes □ No

Infusion pump

you have any questions regarding anything

□ Yes □ No

Stents, coils, filters, or wires in blood vessel

on this form, please do not hesitate to ask

□ Yes □ No

Artificial limb or joint

us.

□ Yes □ No

Eyelid tattoo

□ Yes □ No

Implanted catheter or tube (ex: Swan-Ganz)

□ Yes □ No

Artificial heart valve

□ Yes □ No

Penile prosthesis

□ Yes □ No

Shunt

□ Yes □ No

False teeth, retainers, or magnetic braces

□ Yes □ No

Surgical clips, staples, wires, or stitches

□ Yes □ No

Intrauterine device (IUD)

□ Yes □ No

Ortho devices like plates, screws, pins, and rods

□ Yes □ No

Body piercing

□ Yes □ No

Electrical stimulator for nerves or bones

□ Yes □ No

Tissue expander

□ Yes □ No

Medication patch

□ Yes □ No

Any other implanted device not listedabove:___________________________

Information Concerning Gadolinium Contrast Material

As part of your examination, the radiologist may deem in advisable to give you an I.V. injection of a

contrast agent containing gadolinium. The injection may help to more accurately diagnose your

condition. Although gadolinium contrast agents have been used safely in millions of cases, minor

reactions – principally headaches or nausea – may occur. Serious or life-threatening reactions are

exceedingly rare. Patients over 65 years of age or with known kidney disease will require a blood test

dated within 30 days of the exam to determine if it is safe to give an injection.

□ Yes □ No

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

Do you have a history of renal disease or kidney failure?

I attest that the answers I have provided to the questions

Signature (patient or patient’s guardian):

on this form are correct to the best of my knowledge. I

have read and understand the entire contents of this form

_________________________________________

and have had the opportunity to ask questions regarding

the information on this form.

Date: ___________________________________

Breast Mri Questionnaire Page 2

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