Breast Mri Information Sheet
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1
2BREAST MRI INFORMATION SHEET
#_______________
Patients with pacemakers can NOT have MRI / MRA
Name ____________________________________
Referring MD __________________________ Date __________
Date of Birth _____________
Age _________________
Height _________________ Weight_____________
Contact numbers: Home _____________________
Cell _____________________ Work ______________________
MRI SCREENING INFORMATION
Do you have any of the following devices?
__
Pacemaker or defibrillator
__ Hearing aid
__
Coronary stent
__ Cochlear or Stapedial Implant
__
Cardiac valve replacement
__ Pessary (bladder ring)
__
Brain aneurysm clip
__ Electrical Stimulation Device
__
Breast tissue expander
__ Joint Replacement
__
Medication Patch
__ Shrapnel or Metal Injuries (bullet, metal slivers)
(including a nicotine patch)
CONSENT FOR INTRAVENOUS CONTRAST
Your Doctor has ordered a Breast MRI which requires the administration of intravenous contrast (unless the exam is
solely for the evaluation of implants). The substance we use is called “gadolinium”, a safe, organic substance which will
be excreted by your kidneys within 24 hours. Although this contrast has been shown to be extremely safe, you MUST
inform us of any of the following:
___ Kidney problems including dialysis
___ Sickle cell anemia or sickle cell trait
___ Pregnancy or breast feeding
___ Asthma or respiratory disorders
It is unusual to have any adverse reactions, but the most common noted were; headaches and/or an unusual taste in the
mouth.
I have read the above and give my consent for intravenous contrast: X __________________________________
Patient Signature
BREAST HISTORY
answer to the best of your ability
Do you still menstruate? __Yes __No
If so, what was the start date of your last period? _________
Are you taking hormone replacement therapy? __Yes __No
Have you had Breast cancer? __Yes __No
Ovarian cancer? __Yes __No
Do you have BRCA gene? __Yes __No
Has anyone in your family had:
Breast cancer? ______ Who? _____________________
Age ___________
Ovarian cancer? _____ Who? _____________________
Last mammogram __ Nassau Radiologic Group __ Other facility: Name of facility ____________ year _______
Clinical Concerns: check all that apply
__ You or doctor feels a lump __ Right __ Left
__ Nipple discharge
__ Right __ Left
__ Breast pain
__ Right __ Left
__ Recent breast injury
__ Right __ Left
__ Breast skin changes
__ Right __ Left
__ Abnormal mammo/sonogram
__ Right __ Left
Prior Breast Procedures: check all that apply
__ Fine Needle or Cyst Aspiration
__ Right __ Left
__ Benign __ Malignant
Year_____
__ Needle or Core Biopsy
__ Right __ Left
__ Benign __ Malignant
Year_____
__ Surgical lumpectomy or biopsy/excision
__ Right __ Left
__ Benign __ Malignant
Year_____
__ Mastectomy If you had reconstruction, what type? __ Flap reconstruction
__Implant __Tissue Expander
__ Breast Plastic Surgery If so, what type?
__ Lift
__ Reduction __ Implants (silicone or saline)
Other Treatments: check all that apply
__ Radiation treatment to breast or chest…. Last Treatment Date ___________
__ Chemotherapy….Last Treatment Date _____________
__ Any medication for prevention of breast cancer? ________________
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