2015 Mri Patient Screening Form Page 2
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2MRI Patient Screening Form - Part B
Last Name
First Name
Patient’s preferred language for discussing healthcare
English
Spanish
Other _________________________________
Date of Birth
Date
Claustrophobic? .........................................................
Yes
No
Allergies to any medications? ..............................
Yes
No
Did patient pre-medicate for this exam? ....................
Yes
No
Please List:
If yes, does patient have a driver? .......................
Yes
No
Iron Deficiency being treated with Feraheme .............
Yes
No
Allergies to any seafood or shellfish? ...................
Yes
No
Diabetic? ....................................................................
Yes
No
Allergy to Latex? ...................................................
Yes
No
List any medications taken today and all current medications.
History of Epilepsy (seizures)? ...................................
Yes
No
Include all prescriptions, over the counter items, ointments,
vitamins, and herbals. Attach list if available.
Chronic Heart Disease (CHF)? ...................................
Yes
No
Currently Breast Feeding? ..........................................
Yes
No
Asthma? .....................................................................
Yes
No
History of Diarrhea in past 2-3 days? .........................
Yes
No
History of Falls within past 30 days?..........................
Yes
No
If Yes, when ____________________________________________
Barriers to Learning
Yes
No
Type:
Interventions:
Did the patient receive an IV injection?
Yes
No
Language
Interpreter Used
If yes, attachment A054 must be completed and signed.
Hearing
Repeat Questions
Other _________________________
Family/Significant Other
Prior to release, patient was assessed and found impaired?
Yes
No
If yes, supervising physician notified?
Yes
No
If patient refuses further assessment, notify supervising physician and Alliance personnel to follow policy #5023.
Injection site evaluated?
Yes
No
N/A Note appearance:
Comments:
RECEIPT OF VERBAL ORDERS, TEST RESULTS, MODIFICATIONS, OR OTHER INSTRUCTIONS
Yes
No
Information Received:
Readback confirmed with
Title
Date
Time
Technologist or Radiologist Signature
Date
Time
Post Injection Instructions given (applicable to all patients who receive an injection). ............................................
Yes
No
N/A
Patient notified of rights and opportunity to “Speak Up” with questions or concerns. ...........................................
Yes
No
Handoff Report given to next provider of care. Medication list provided if applicable. ...........................................
Yes
No
N/A
If retail, Patient Rights & Responsibilities provided to the patient. ..........................................................................
Yes
No
N/A
Patient received ear protection. ...............................................................................................................................
Yes
No
Are patient reminder calls for this site made by Alliance Team Members? ..............................................................
Yes
No
EMR
If yes to above and NOT documented in an EMR or Intergy, complete row below.
Team Member Name:
Date:
Time:
Summary:
Clinical Pause #2 conducted prior to image transfer?
Yes
No
Tech Initials ________
Team Member Signature and Title:
PATIENT SIGNATURE BELOW ONLY AT THE COMPLETION OF EXAM.
I did not leave any personal belongings upon completion of exam.
Revised January 1, 2015
Attachment A007
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