Mri Breast Patient Information

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MRI Breast
Patient Information
Exam date ______________________
Patient name __________________________________________________________ DOB _____________
 Female  Male
Height _____________________ Weight _________________
If patient is a minor, parent’s name ____________________________________________________________
1. Is there any chance of pregnancy?  Y
 N
Date of last menstrual period _______________________
2. Are you currently breast feeding?  Y
 N
3. Have you ever had an eye injury requiring medical attention?  Y
 N If yes, please describe:
_____________________________________________________________________________________
4. The following items can interfere with MR imaging; please check if you have any of these:
Cardiac Pacemaker
Harrington rod
Brain clips
Bone or Joint pins
Aortic clips
Artificial Joint or Prosthesis
Neurostimulators (TENS-UNIT)
Metal mesh
Heart Valve
Wire sutures
Insulin pump
Shrapnel
Electrodes
Dentures or Removable Dental Work
Hearing Aid
Metal fragments in head, eye, body
IUD
Cochlear / Stapes implants
Shunt
Fractured bones (pins, plates, metal rods,
Stent
screws)
Breast expanders
OTHER; Please list: __________________
Penile Implant
Medication Patch
5. Please mark on the drawing the location of any known or
suspected metals inside your body:
6. Please review the list below and remove any of these articles. Lockers will be provided before entering
the MRI suite
(Glasses, dental work and shoes can remain with you until you enter the exam room):
Hair pins, barrettes
Back brace
Jewelry (other than 14K rings)
Metal bra hooks
Watch / Keys
Bra & Girdle underwire support
Magnetic strip cards
Sanitary belt
Safety pins
(Credit & Bank cards)
Wallet / Money Clip / Coins
Hearing aides
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