Wayne Mri Patient Screening Form Page 2
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2YES _____ NO _____
1. Are you over 65 years old?
YES _____ NO _____
2. Are you diabetic?
YES _____ NO _____
3. Do you have/had kidney disease or kidney surgery?
YES _____ NO _____
4. Have you ever had chemotherapy?*
If yes, when? Month___________ Year______
YES _____ NO _____
5. Have you ever had Radiation Therapy?*
If yes, when? Month___________ Year______
YES _____ NO _____
6. Do you have a history of multiple myeloma?
YES _____ NO _____
7. Do you have rheumatoid arthritis?
YES _____ NO _____
8. Do you have scleroderma, lupus, dermatomyositis, or
Wegener’s Disease?
YES _____ NO _____
9. Do you have AIDS/HIV?
Patient Signature: __________________________________________________
DATE: ____________________
IF THE PATIENT ANSWERS YES TO ANY ONE OF THESE QUESTIONS, WE MUST
HAVE A CREATININE WITHIN THE PAST 30 DAYS.
* Creatinine only needed for patients who have had chemotherapy or radiation therapy within
the past 3 months.
____________________________________________________________________
TO BE FILLED OUT BY MRI STAFF:
Technologist: _________________________________________________________ DATE: ___________________________
Creatinine: ________ Creatinine Clearance: ________
Creatinine Clearance Between 30 and 60 Approved by: _____________________________________
CONTRAST:
PRODUCT: ____________________ LOT: __________ EXP DATE: __________ AMT: ____________
APPROVAL OF ANY METALLIC HARDWARE: __________________________________________________________________
PREVIOUS MRI SCANS?
(Please circle)
YES
NO
DATE ______________
If yes, where?
PACS ON CART OUTSIDE FACILITY
MJ PURGED
COMPARISON X-RAYS TODAY?
(Please circle)
YES
NO
PRIOR COMPARISON X-RAYS?
(Please circle)
YES
NO
DATE ______________
If yes, where?
PACS ON CART OUTSIDE FACILITY
MJ PURGED
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