Patient Intake
Privacy Acknowledgement

Patient Name

Date of Birth

Age

SexMaleFemale

Weight

Height (ft)

Height (in)

Brief summary of symptoms

Are you claustrophobic?YesNo

Please speak with your ordering physician about medication prior to your scheduled examination.

Previous exams to the body part being imaged?YesNo

If yes, when and at what facility?

Joint injection in the last 7 days?YesNo

If yes, which joint?

Eye injury involving metal?YesNo

If yes, was it removed by an eye doctor?YesNo

Have you ever received CT or MRI contrast?YesNo

If yes, any adverse reactions?

Kidney disease?YesNo

Kidney transplant?YesNo

Dialysis?YesNo

Do any of the following apply to you?

Diabetes

Sickle Cell

Multiple Myeloma

Any Blood Disease?

YesNo

Please explain

Have you had, or do you currently have cancer?

YesNo

If yes, what kind?

Did you receive chemo?

YesNo

Radiation?

YesNo

Are you currently breastfeeding?

YesNo

The following items can interfere with the MRI and some may be hazardous to your safety. Shall you fail to disclose any implanted devices or hardware, your scan may be delayed to a later date pending verification of safety conditions.

Please answer Yes or No to all of the following. If yes, please elaborate.

Cardiac pacemaker, defibrillator, or loop recorder?

YesNo

Please explain

Any implanted electronic stimulators? Ex: nerve, bladder, vagal nerve, deep brain, bone growth, or sleep apnea.

YesNo

Please explain

Aneurysm clips, coils, or implanted brain devices?

YesNo

Please explain

Any artificial heart valves, occluders, or Watchman devices?

YesNo

Please explain

Shunts? VP (gravity fed or adjustable)/spinal/ other?

YesNo

Please explain

Any blood clot filters?

YesNo

Please explain

Implanted drug pumps? (pain, insulin, chemo)

YesNo

Please explain

Any eye surgeriesCataractGlaucomaRetinaOther

Other

Cochlear implants?

YesNo

Any replaced ear bones?

YesNo

Please explain

Spinal hardware?

YesNo

Location

Joint replacement?

YesNo

Location

Prostate patients: Do you have a penile implant, Urolift, or radiation seeds?

YesNo

Please explain

Diabetic patients: Do you have a removable insulin pump or glucose monitor?

YesNo

Please explain

Breast patients: Do you have a biopsy marker or tissue expanders prior to implants?

YesNo

Please explain

If you have a medical device card for any surgically implanted device, please provide this PRIOR to scheduling.

I have a medical device card

YesNo

When and where was your surgery performed?

Devices that must be removed prior to scan:

Hearing aids
Drug pumps
Foil backed medicine patches
Prosthetic limbs
Dentures

Please list ANY and ALL surgical history

List Your Medications

List Any Allergies

MRI-Pregnancy Consent

POLICY: All female patients between the age of 12 and 55 years of age who will have an MRI procedure are required to read and complete this form.

LMP (First Day of Last Menstrual Period)

Birth Control?

YesNo

IUD/Essure?

YesNo

Menopause?

YesNo

MRI EXAM: I realize that the FDA has not established any criteria under which pregnant women can have an MRI exam. Current research information does not indicate that MRI is either safe or unsafe for the developing fetus. Any potential risks to the fetus are unknown. If possible, confirmation of pregnancy/ non-pregnancy for females who could possibly be or become pregnant is important prior to performing an MRI exam. Patients that are NOT within the first ten days of their last normal menstrual period will have an onsite urine HCG test performed by the MRI Technologist prior to the MRI exam.

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