Element Medical Imaging


MRI Screening Form

 
Patient Information
Symptoms
Are these symptoms due to an injury?
  
Have you had prior surgery on this area?
  
Have you had prior imaging done on this area (MRI, CT, XRay, etc.)?    

Safety Screening
Please indicate if you CURRENTLY HAVE or HAVE EVER HAD any of the following:
Any type of electronic, mechanical or magnetic implant
Any cardiac pacemaker, defibrillator or other cardiac implant
Neurostimulator, diaphragmatic, deep brain, vagus nerve, bone growth, spinal cord or any biostimulator
Implanted drug pump (insulin pump, baclofen pump, chemotherapy, or pain pump)
Internal electrodes or wires
Any type of coil, filter or stent
Artificial heart valve
Ear implant (cochlear, stapes, etc.)
Any type of implant held in place by a magnet?
Aneurysm clip
Spinal fixation device
Penile implant
Eye implant (coil, spring, weight)
Tissue expander (breast)
If you have any of the implanted devices above please be prepared to present the model, serial number and implanting doctor.
 
Any IV access port (PICC line, Hickman, Broviac, Port-a-Cath, etc.)?
Artificial limb or joint
IUD
Foreign body (BB, bullet, shrapnel)
Metal shavings in eye
Removable dentures or partial plate
Removable drug pump (insulin, baclofen, etc.)
Medication patch (nitro, nicotine, glucose, etc.)
Have you recently swallowed a pill cam
Bobby pins, barrettes, weaves, clips, extensions
Magnetic eyelashes or magnetic nail polish
Metal-containing clothes/underwear/bra
Surgical mesh
Radiation seeds
Plates, pins, rods, screws
Permanent makeup/tattoos
Hearing aids
Diaphragm, pessary
Body piercings
Jewelry
Wig or hair implants
Fitness tracker (Fitbit, etc.)
Electronic monitoring device
Any other type of surgically implanted devices, removable devices or personal items not covered?
Health History
Please answer the following questions about your health history
Are you claustrophobic?
Have you previously received contrast (dye) for an MRI?
Are you diabetic?
Diagnosed with kidney disease
Single kidney
Asthma/respiratory disease
Hypertensive (high blood pressure)
Kidney transplant
Are you on dialysis?
Personal history of cancer?
Have you had a colonoscopy in the last 90 days?
Have you been hospitalized in the last 30 days for dehydration, febrile illness, sepsis, heart failure, liver disease or abdominal surgery?
For female patients only:
Is there a possibility you are pregnant?
Are you post-menopausal?
Are you breastfeeding?
You will be provided with hearing protection before your scan. You are strongly urged to use the earplugs or headphones provided to you during your MRI. Some patients find the noise levels unacceptable, and the noise levels may affect your hearing if these provided hearing protection devices are not utilized.

Because some clothing may contain metal even when not apparent, the MRI technologist may instruct you to remove clothing. MR safe clothing will be provided to you to wear during your MRI scan. This is being done to help ensure your safety during your examination.

Please be prepared to remove the following items prior to your MRI:
Jewelry    Piercings    Hair Pins    Bobby Pins    Barrettes    Hair Clips    Wigs    Shoes    Watches    Dentures    Partial Plates    Eyeglasses    Hearing Aids    Cell Phones    Pagers    Cards w/ Magnetic Strips
Signature of Patient/Guardian (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
 
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