Attch 7-MRI Screening Form (for Site Visit Only).pdf

Department of Veterans Affairs MRI Screening Form (For Patients)

VETERAN’S LAST NAME, FIRST NAME, MI

MANN-GRANDSTAFF VAMC

SPOKANE, WASHINGTON

03/2014

MRI SCREENING FORM (FOR PATIENTS)

(DIAGNOSTIC IMAGING SERVICE)

PATIENT ID # (DO NOT use complete SSN)

VETERAN’S DATE OF BIRTH (DD MMM YY – i.e. 04 Jul 76)

OP FORM 668-RAD-004 (2014)

Today’s Date Patient’s Age Patient’s Height Patient’s Weight Gender:

Male Female

Body Part to be Examined: ___________________________________________________________________________ Mailing Address: ___________________________________________________________________________________ City, State, Zip Code: ________________________________________________________________________________ Primary Phone ( Home / Cell / Work): ____________________________________________________________ Alternate Phone ( Home / Cell / Work): ___________________________________________________________ Reason for MRI and/or Symptoms: _____________________________________________________________________ Referring Physician’s Name: __________________________________________________________________________ Referring Physician’s Phone: __________________________________________________________________________

QUESTIONNAIRE YES NO N/A

1. Have you had prior surgery or an operation (e.g., arthroscopy, endoscopy, etc.) of any kind?

If yes, indicate date: ____/____/____ and type of surgery:

If yes, indicate date: ____/____/____ and type of surgery:

2. Have you had a prior diagnostic imaging study or examination (MRI, CT, Ultrasound, X-Ray)?

- MRI Date Body Part Facility

- CT/CAT Scan Date Body Part Facility

- X-Ray Date Body Part Facility

- Ultrasound Date Body Part Facility

- Nuclear Medicine Date Body Part Facility

- Other: Date Body Part Facility

3. Have you experienced any problem related to a previous MRI Examination or MR Procedure

If Yes, please describe

4. Have you had an injury to the eye involving a metallic object/fragment (e.g., sliver, shaving, etc.)?

If Yes, please describe

5. Have you ever been injured by a metallic object or foreign body (e.g., BB, shrapnel, bullet, etc.)?

If Yes, please describe

6. Are you currently taking or have you recently taken any medication or drug?

If Yes, please describe

7. Are you allergic to any medications?

If Yes, please describe

8. Do you have a history of asthma, allergic reaction, respiratory disease, or reaction to a contrast medium or dye used for an MRI, CT, or X-Ray examination?

9. Do you have any anemia or any disease(s) that affect your blood, a history of renal (kidney) disease or seizures?

If Yes, please describe

FOR FEMALE PATIENTS: YES NO N/A

10. Date of last Menstrual Period: ____/_____/____ Are you Post-Menopausal?

11. Are you pregnant or experiencing a late menstrual period?

12. Are you taking oral contraceptives or receiving hormonal treatment

13. Are you taking any type of fertility medication or having fertility treatments?

14. Are you currently breast-feeding?

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Department of Veterans Affairs MRI Screening Form (For Patients)

VETERAN’S LAST NAME, FIRST NAME, MI

MANN-GRANDSTAFF VAMC

SPOKANE, WASHINGTON

03/2014

MRI SCREENING FORM (FOR PATIENTS)

(DIAGNOSTIC IMAGING SERVICE)

PATIENT ID # (DO NOT use complete SSN)

VETERAN’S DATE OF BIRTH (DD MMM YY – i.e. 04 Jul 76)

OP FORM 668-RAD-004 (2014)

WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with the procedure. DO NOT ENTER the MR system room or MR environment if you have any question or concern regarding an implant, device or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS ON.

IMPORTANT INSTRUCTIONS: Before entering the MR environment or MR system room, you must remove ALL metallic objects including phone, eyeglasses, hair pins, barrettes, jewelry, body piercing, watch, safety pins, paper clips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, and clothing with metallic threads.

Please indicate if you have any of the following:

Yes No Aneurysm Clip(s) Please mark the figure(s) below with the location of any implants or metal inside of or on your body

NOTE: You may be advised or required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems or hazards related to acoustic noise.

Yes No Cardiac Pacemaker

Yes No Implanted Cardioverter Defibrillator (ICD)

Yes No Electronic implant or device

Yes No Magnetically-activated implant or device

Yes No Neurostimulation system

Yes No Spinal cord stimulator

Yes No Bone growth / bone fusion stimulator

Yes No Cochlear, otologic or other ear implant

Yes No Any type of prosthesis (eye, penile, etc.)

Yes No Heart valve prosthesis

Yes No Eyelid spring or wire

Yes No Artificial or prosthetic limb

Yes No Metallic stent, filter or coil

Yes No Shunt (spinal or intra-ventricular)

Yes No Vascular access port and/or catheter

Yes No Radiation seeds or implants

Yes No Swan-Ganz or thermo-dilution catheter

Yes No Medication patch (Nicotine, Nitroglycerine)

Yes No Any metallic fragment or foreign body

Yes No Wire mesh implant

Yes No Tissue expander (e.g., breast)

Yes No Surgical staples, clips, or metallic sutures

Yes No Joint replacement (hip, knee, etc.)

Yes No Bone/joint pin, screw, nail, wire, plate, etc.

Yes No IUD, diaphragm, or pessary

Yes No Dentures or partial plates

Yes No Tattoo or permanent makeup

Yes No Body piercing jewelry

Yes No Hearing Aid

Yes No Other implants:

Yes No Breathing problems or motion disorder

Yes No Claustrophobia Signature of Person Completing Form

Relationship Date

Form Reviewed by:

Cleared to Enter?

Yes No

Date

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