MRIScreeningrecordEmerge

Magnetic Resonance Imaging

SCREENING RECORD

NAME

DATE

DOB

Drug Allergies

Yes No

If yes, list Allergies:

Patient Weight

Patient Height ft.

In.

Your doctor has ordered an MRI examination to help determine your diagnosis. The following items can interfere with MRI imaging and some can be hazardous to your safty.

Please check the approiate boxes:

Cardiac (Heart) Pacemaker

YES NO

Prosthetic Heart Valve

YES NO

If yes, list make and model

Patient Ambulatory (Able to walk & stand)

YES NO

Patient Claustrophobic

YES NO

If yes, does pt. need to have meds from referring?

YES NO

Surgery within the last 8 weeks

YES NO

Implated Devices

YES NO

Aneurysm Clip or Surgery (If yes, op notes needed)

YES NO

Vascular Stents (ie, Abdomen/Pelvis, Carotid)

YES NO

Prior Vascular Surgery (e.g. Heart, Kidney, Brain, Vein)

YES NO

Prior Spine Surgery

YES NO

Middle Ear Prosthesis (Cochlear, Staple Implant)

YES NO

Breast Implant/Tissue Expander

YES NO

Known or Possible Pregnancy

YES NO

Currently Breast Feeding

YES NO

Male Only - Penile Implant

YES NO

If yes, list make & model

Metal Worker or Possible Metel Fragments in the Head, Neck, Torso

YES NO

(e.g. Welders, Machinists, Gunshot Wound, Metal Rods, Screws, Plated, Shrapenel

Is clearance needed for any of the above criteria?

YES NO

Joint Replacement

YES NO

If yes, be specific

History of Cancer

YES NO

Allergic to Latex

YES NO

Drug Patches

YES NO

Body Piercing

YES NO

Eye Liner Tattoo

YES NO

DO NOT ENTER THE MAGNET ROOM WITH ANY OF THE FOLLOWING:

Heart Pacemaker
Jewelry
Any Electronic Device

Watches
Hair Pins
Hearing Aid
Dentures

Keys
Barretts
Earrings

Credit Cards
Pens
Belts

Coins
Pocket Knife
Safty Pins

CREATININE TESTING

Creatinine Location Drawn

FOR TECHNOLOGIST USE ONLY

Creatinine Date (Must be within 30 days)

GADOLINIUM

The radiologist may deem it nessessary to give you the I.V. injection of a contrast liquid containing galolinium to improve the quality of your MR examination. Although gadolinium contrast agents have been used safely in millions of patients, minor reactions (principally headache or nausea) occur in 2% of patients, and serious or life threateningreactions have been reported in 1 in 400,000 patients.

History of previous reaction

YES NO

If yes, explain (reaction)

Asthma or emphysema

YES NO

GFR acceptable range >51
GFR 30-50 - half dose
GFR <30 - contact Radiologist

FOR TECHNOLOGIST USE ONLY

Manuf

Amount

Injection site

Lotnumber

Exp. Date

Injected By:

Post Observation