Mri Screening Form & Patient History Page 2
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1
2Yes
No
Have you ever had a reaction to IV contrast? What kind?
Yes
No
Drug allergies
Are you wearing any medication patches today?
Yes
No
For all MALE patients
Yes
No
Do you have a penile implant? If so, what kind?
For all FEMALE patients
Yes
No
Do you have a diaphragm, IUD or pessary in place?
Yes
No
Are you pregnant? Last menstrual period?
Are you breast feeding?
Yes
No
If you have any of the following, please check all those that apply to you:
Headaches
Dizziness (vertigo)
Stroke
Respiratory Disease
Asthma
Leukemia
Sickle Cell Anemia
Liver Disease
Kidney Disease
List all other
previous surgeries:
ALL METAL (including jewelry and clothing with metal) MUST BE REMOVED PRIOR TO ENTERING THE MRI SUITE. A LOCKER AND MRI
APPROVED CLOTHING WILL BE PROVIDED. PLEASE NOTE: IF YOU ARE NOT WEARING CLOTHING WITH METAL, YOU MAY STILL BE
REQUIRED TO CHANGE CLOTHES - DEPENDING ON THE BODY PART BEING IMAGED.
I understand this information presented to me and have answered these questions truthfully and to the best of my knowledge.
Date
Patient/Parent/Legal Guardian
Technologist/Witness
Technologist/Nurse/Paramedic section:
Omniscan
cc
with a __________________ ga. @ _________ am pm
_________ by _________
Multihance
time
# of punctures
Magnevist
____________________ Lot # _________________________________ Expiration Date _____________________________
site of injection
Physician/paramedic providing contrast coverage: ________________________________________________________________
Contrast reaction: YES
NO
Explain: ______________________________________________________________________
Contrast extravasation: YES NO ______________________________________________________________________________
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