Date: xx/xx/xxxx This test may take up to 1 hour. For your comfort, please use our restroom facilities before your scheduled appointment.
Are you claustrophobic (afraid of tight spaces)? yes no If yes, notify the front desk immediately. First Name: Middle: Last: Birthdate: xx/xx/xxxx Age: Sex: Male Female Weight: lbs. Email Address:
Requesting Doctor: Reason for this examination:
Patient History and Screening: A. Please list allergies: B. If female, is there any possibility of being pregnant? yes no Last Menstuation Period? xx/xx/xxxx C. Any previous radiologic exams (i.e. MRI, CT, Myelogram, Angiogram, X-Ray) of part of body being studied today? yes no If yes, Date, Type of Surgery and Where Preformed? 1. 2. D. Have you had surgery other than detal surgery yes no If yes, please check location of surgery. Brain Eye Sinus Ear Neck Chest Back Abdomen Extremities Other Date, Type of Surgery and Where Preformed? 1. 2.
E. Does your occupation expose you to metal fragments? yes no (i.e. sheet metal shop, auto body shop) F. Have you ever had metal fragments in your eye? yes no Medical Condition High Blood Pressure yes no Diabetes yes no Seizures yes no Other Medical Conditions Have you had a TUMOR? yes no If yes, specify type and location Have you ever had Chemotherapy? yes no Have you ever had radiation Therapy? yes no If yes, when and which hospital Do you take Steroid medication? yes no Have you had any steroid injections? yes no If yes, when and where Do you take Anticonvulsants? (medicine for seizures) yes no Any other medication? Patient History and Screening Clinical Information Head Seizures Left Right Headaches Left Right Dizziness Left Right Fainting Spells Left Right Speech Difficulty Left Right Memory Loss Left Right Paralysis Left Right Weakness Left Right Numbness Left Right Hearing Loss Left Right Spine Neck Lump Left Right Neck Pain Left Right Neck Swelling Left Right Arm Pain/Numbness Left Right Upper Back Pain Left Right Lower Back Pain Left Right Leg Cramps When Walking Left Right Chest Coughing Blood Shortness of Breath Pain Left Right Mass Left Right Abdomen Nausea/Vomiting Vomiting Blood Blood in Stool Blood in Urine Jaundice Diarrhea Constipation Pain Left Right Mass Left Right
The following items can interfere with the MR imaging and your safety. Please check if you have any of these items in your body. Cardiac Pacemaker Brain Clips Carotid Clips Neurostimulators (Ten-Units) Heart Valve Insulin Pump Electrodes Hearing Aides of Implants Fractured Bones Treated With Metal Rods, Screws, Nails or Clips Harrington Rod Bone or Joint Pins Prosthesis Metal Mesh Wire Sutures Shapnel Dentures Others (please list) If any of the above are checked, what is the location on the body? None of the Above (must be checked if none of the above items apply)
Consent Form Required: I do not have electronic devices or metal of any type in, or attached to, my body. I certify that I have read and answered all questions. I will not hold any person or institution responsible for any possible omission made here.
