MRI Patient Questionnaire

MRI Patient Questionnaire

Patient Name: Date:

Referring Provider: Date of Birth:

Weight: Height:

Personal History

Cardiac Pacemaker– (circle one only please)YesNoBone growth/bone fusion stimulatorYesNo

If Yes, Medtronic RevoSureScan or Advisa DR MRI SureScanOther implantYesNo

Implanted cardioverter defibrillator (ICD)YesNoAny metallic fragment or foreign bodyYesNo

Neurostimulation systemYesNoRadiation seeds or implantsYesNo

Aneurysm clip(s)YesNoInternal electrodes or wiresYesNo

Tissue expander (e.g. breast)YesNoHeart valve prosthesisYesNo

Cochlear, otologic, or other ear implantsYesNoJoint replacement (e.g. hip, knee)YesNo

Metallic stent, filter, or coilYesNoWire mesh implantYesNo

Shunt (spinal or intraventricular)YesNoIUD, diaphragm, or pessaryYesNo

Any type of prosthesis (eye, penile, etc.)YesNoArtificial or prosthetic limbYesNo

Implanted drug infusion deviceYesNoTattoo or permanent make-upYesNo

Spinal cord stimulatorYesNoBreathing problem or motion disorderYesNo

Eyelid spring or wireYesNoAre you diabetic?YesNo

Pill cam capsule endoscopy deviceYesNoBody piercing jewelryYesNo

Surgical staples, clips, or metallic suturesYesNoDentures or partial platesYesNo

Medication patch (Nicotine, Nitroglycerine)YesNoAre you pregnant?YesNo

Bone/joint pin, screw, nail, wire, plate, etc.YesNo

Magnetically-activated implant or device; or electronic implant or deviceYesNo

Swan-Ganz or thermodilution catheter or vascular access port and/or catheterYesNo

Hearing aids (Remove before entering MRI system room)YesNo

Injury to eye by metallic object: if yes – was it removed by a physician? ☐ Yes ☐ NoYesNo

IMPORTANT INSTRUCTIONS: Before entering the MR environment or MR system room, you must remove all metallic objects including hearing aids, dentures, partial plates, keys, beepers, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clippers, tools, clothing with metal fasteners, & clothing with metallic threads.

I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and have had the opportunity to ask questions regarding the MR procedure that I am about to undergo.

Form Completed By: Signature:

Relationship to Patient: Date:

For Staff Use Only:

Reviewed By:
Staff: Date: Staff: Date:

Patient Name: Date:

Reason for examination?

Are your symptoms related to an accident or injury?YesNoDate?

Type of accident or injury:

Is this exam a follow up to a prior injury or medical condition? Yes No (Specify):______

Have you had surgery on the body part(s) being scanned today?YesNo

What procedure was performed?

Date: Facility: Provider:

Please list any other known medical conditions:

Do you have a personal history of cancer? YesNoWhere?

What medications are you currently taking?

Allergy or any reactions to MR contrast (Gadolinium)YesNo

Are you allergic to any medications?YesNo

Please list:

Are you allergic to LATEX products? YesNo

Circle Symptoms as they Apply to your Specific Exam

Body MRI
Difficulty SwallowingYesNoNausea or VomitingYesNo
DiarrheaYesNoConstipationYesNo
Jaundice (yellow skin)YesNoPainYesNo
Brain MRI
Headaches/PainYesNoSeizuresYesNo
WeaknessYesNoHearing ProblemsYesNo
Visual ProblemsYesNoNumbnessYesNo
Speech ProblemsYesNoDifficult WalkingYesNo
Difficult ThinkingYesNo
Eye MRI
Which eye is involved?RightLeftBothIs your vision affected?YesNo
Blurred: Loss Of: Double Vision: PainYesNo
IACS or TMJ
EarPain R LRinging RL Deafness RL Pressure RL Hearing LossRL
TeethPain R LGrinding RL Sensitivity RL Clicking RL LockingRL
NeckPain R LStiffness RL
Musculosketal
PainYesNoLockingYesNo
SwellingYesNoInfectionYesNo
MassYesNo
Spine MRI
PainBackNeckRight LegLeft LegRight ArmLeft Arm
WeaknessBackNeckRight LegLeft LegRight ArmLeft Arm
NumbnessBackNeckRight LegLeft LegRight ArmLeft Arm

Have you had previous radiology studies on the body part(s) being scanned today?

MRILocation:

MRILocation:

CTLocation:

CTLocation:

ULLocation:

X-RayLocation:

MRI Patient Questionnaire8.24.15(719) 785-9000

877-6-PENRAD • (877) 673-6723

PENRAD.org