MRI Screening MRI HISTORY AND SCREENING FORM Choose Location * ---AugustaAustin CentralBirminghamBuckheadCantonCareersCummingDallasDecaturFayettevilleGrandviewHiramLawrencevilleMariettaNewnanSan AntonioSandy SpringsStand-up Mri AtlantaTallahasseVestaviaWest Cobb Patient’s Name: Date of Birth: Sex: MaleFemale Height: Weight: Reason you are here today? Explain your medical problem in detail. (What is the problem? Where is the problem? Etc...): Is your problem related to an injury?: YesNo If yes, Date of injury?: How were you injured?: WorkMotor Vehicle AccidentOther Have you taken any sedation/alcohol today to relax you for this procedure?: YesNo If yes, What?: If yes, do you have someone to drive you home?: YesNo Do you have or have you ever had any of the following? YesNoCardiac Pacemaker?: YesNoHeart Surgery/Heart Valve: If Yes, explain: YesNoImplanted Cardiac Defibrillator (ICD): YesNoBrain Aneurysm Clips/ Brain Surgery: If Yes, explain: YesNoShunts/Stents/Filters/Intravascular Coil: YesNoEye Surgery/Implants/Spring/Wires/Retinal Tack: YesNoInjury to the Eye Involving Metal or Metal Shavings: YesNoOrthopedic Pins/Screws/Rods/Joints/Prosthesis: YesNoNeurostimulator/Biostimulator: YesNoHistory of Cancer or Tumors: When: Where: YesNoRadiation Therapy/Chemo Therapy: YesNoPrevious Back Surgery (Lumbar/Thoracic/Cervical): When: Level: YesNoEar Surgery/Cochlear Implants/Hearing Aids/Stapes Prosthesis: YesNoVascular Access Port/Catheter: YesNoMetal Mesh Implants/Wire Sutures/Wire Staples or Clips/Internal Electrodes: YesNoElectrical/Mechanical/Magnetic Implants? Type: YesNoImplanted Drug Infusion Pump/Insulin Pump: YesNoAre you Pregnant? When was your last Menstrual Period/Cycle? YesNoTattoo’s/Permanent Make-up/Body Piercing/Patches: YesNoDentures/Partials/Dental Implants: YesNoGunshot Wounds/Shrapnel/BB: YesNoDo you have pins in your Hair/Clothes/Hair Extensions/Hair Pieces/Wig: List any Drug Allergies: List Previous Surgeries: List any Medications you’re presently taking: If you wear Habitrol and/or Transderm Scop patches they must be removed before you enter the MRI room. No exceptions. MRI Contrast History: Have you ever had MRI contrast?: YesNo Did you have any kind of reaction?: YesNo If yes, explain: Are you breast feeding at this time?: YesNo Do you have any history of Renal disease?: YesNo Do you have any history of Hypertension?: YesNo Do you have any history of Diabetes?: YesNo Have you ever had severe hepatic disease or liver transplant or pending liver transplant?: YesNo I attest that the above information is correct to the best of my knowledge. I have also informed the technologist that I am not pregnant at this time and I give consent to have a contrast agent administered to me if needed for proper diagnosis of my procedure. I acknowledge that I am aware of the possibility of side effects with contrast and I have had the opportunity to ask questions related to this form, to ask questions regarding the MRI procedure, and I understand the information presented to me. Patient/Parent/Legal Guardian Signature Technologist’s Signature Date: FOR TECHNOLOGIST USE ONLY Type of Contrast: Lot Number: Time of Injection: Contrast Temperature: Expiration Date: Amount: If you need to print a copy for office records, please select the Print button before submitting.