Mri Patient Questionnaire Template
ADVERTISEMENT
1MRI Patient Questionnaire
Your Name:____________________________ Age____Weight____ lbs
Sex M F
SOME PEOPLE CANNOT HAVE AN MRI EXAM, THEY CANNOT GO NEAR THE MRI SCANNER
Do you have (or ever had) any of the following?
Y
N
A medical device in your body such as a pacemaker
Y
N
Surgical aneurysm clip in the brain
Y
N
Metal fragments (or rust) in the eye
Y
N
Have you ever worked in a machine shop or similar environment where you may
have been subjected to small metal slivers, particularly in the eyes?
Y
N
Any other metal or object in your body (shunt, stent) _________________
Y
N
Nerve or bone stimulator
Y
N
Drug infusapump
Y
N
Eye or ear implant
Y
N
Transdermal patches i.e.: nitroglycerin, nicotine, HRT/tattoo
Y
N
Are you pregnant or nursing? When was your last menstrual period _____
Y
N
IUD
Please describe in your own words your present complaint of problem. How long ago did it start?
What does your doctor think is the cause? ____________________________________________
______________________________________________________________________________
Are you here as a result of a CAR ACCIDENT?
Y
N
WORK ACCIDENT
Y
N
If yes, please give us date of accident ____________/______/_______
Please check all of the diseases in this list that you have either had in the past – or for which you are
now under treatment:
___High blood pressure
___Cancer*(specify below)
___Diabetes
___Heart disease
___Hereditary disease*
___Immune Deficiency
___Surgery on head*
___Asthma
___Pituitary/Hormone disease
___Stroke/bleeding in brain
___Multiple sclerosis
___Epilepsy
___Sickle cell disease
___Physical therapy
___Allergies; If yes please list
___Previous surgeries
________________________
______________________________________________________________________________
Have you eaten anything in the last four hours?
Y
N
Do you have any of the following signs/symptoms or have you had any of the following treatments?
(Please check all that apply):
___Difficulty walking
___Difficulty speaking
___Physical therapy
___Paralysis/weakness of
___Fever, night sweats
___Previous MRI
any body part
___Radiation
___New onset seizures
___Claustrophobia
___Previous Gadolinium injection
___Problems with vision or
___Dizziness
___Previous exam for this complaint-
hearing
X-RAY-US-CT
Shade figures below to highlight areas of pain or discomfort.
POSTERIOR
ANTERIOR
RIGHT
RIGHT
LEFT
LEFT
To the best of my knowledge the above information is true and correct.
Signed Patient ______________________________________ Date ____________________
Signed Interviewer ___________________________________ Date ____________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life