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Microsoft word - mri and ct screening

MRI/CT SCREENING

Patient Name: ______________________________ DOB: _________________ Date: _______________________
Sex: ______________ Weight: _____________________
Injury Information: Work Automobile Fall Other Date of injury: __________________________
Draw where you are experiencing your symptoms:
Describe your symptoms/injury/reason for
procedure:
List any previous exams related to the body part being scanned today:
Is there any chance you might be pregnant? Y N N/A Date of last period: ____________________________ Are you breastfeeding? Y N N/A Are you allergic to anything? Y N If yes, please list: _____________________________________________________ Medications you are currently taking: _____________________________________________________________________ ____________________________________________________________________________________________________ Have you ever had an allergic reaction to MRI/CT contrast/dye? Yes No If yes, please explain: ___________________________________________________________________________ List previous surgeries: _________________________________________________________________________________ CT Examinations Only:
Not applicable

Are you taking Glucophage, Glucovance, Avandemet, Metaglip or Fortamet?
Have you ever had any history of the following?
MRI Examinations Only:
Not Applicable
Do you have any of the following? Metal in eye? Including metal shavings? If yes, explain: ________________________________________ Metal mesh implants/wire sutures/internal electrodes/wire staples? If yes, explain: ____________________ Gunshot wounds/shrapnel/BBs? If yes, explain: ________________________________________________ Any electrical, mechanical, or magnetic implants? If yes, explain: _________________________________ Implanted drug infusion pump/insulin pump? If yes, explain: _____________________________________ Dentures, partials, or dental implants? If yes, explain: ___________________________________________ Tattoos/permanent makeup/body piercings? If yes, explain: ______________________________________ Shunts/stents/intravascular coil? If yes, explain: _______________________________________________ Implanted cardiac stimulator? If yes, explain: _________________________________________________ Pacing wires/ Swann GANZ catheter? If yes, explain: ___________________________________________ Orthopedic pins, screws or rods? If yes, explain: ______________________________________________ Neurostimulator/biostimulator? If yes, explain: ________________________________________________ Heart surgery/Heart valve/pacemaker? If yes, explain: __________________________________________ Yes No Brain surgery/brain aneurysm clips? If yes, explain: ____________________________________________ Yes No Eye surgery/implants? If yes, explain: _______________________________________________________ Ear surgery/Cochlear implants? If yes, explain: _______________________________________________ Do you have diabetes? If yes, explain: _______________________________________________________ History of cancer or tumors? If yes, explain: __________________________________________________ Previous back surgery? If yes, explain: _______________________________________________________ Do you have multiple myeloma? If yes, explain: _______________________________________________ Are you on renal dialysis? If yes, explain: _____________________________________________________ Do you have renal or kidney disease? If yes, explain: ___________________________________________ Do you have liver disease? If yes, explain: ____________________________________________________ Have you had a liver transplant? If yes, explain: _______________________________________________ Do you have hypertension? If yes, explain: ___________________________________________________ Do you have a blood disorder or sickle cell? If yes, explain: ______________________________________ I hereby consent to the performance of this procedure selected by my doctor, with whatever medication or treatment is necessary for the safe completion of this procedure. I authorize Southwest Diagnostic Centers to do whatever may be necessary in the event any unforeseen conditions arise during the course of this procedure. A small percentage of MRI patients may experience transient skin irritation from radio frequency of the MRI. A small percentage of CT patients may experience allergic reaction to the IV contrast administered with some CT exams. I agree the above information is correct to the best of my knowledge. I have read and understood the entire contents of this form and I have had the opportunity to ask any questions regarding information on this form. Patient Signature ________________________________________________________________ Date: ______________________ Technologist Signature ___________________________________________________________ Date: ______________________ For Office Use Only:
BUN ________________ Creatinine _________________ N/A Contrast Administration: ________________CC of _________________________ with a ________________________ @ ___________________ Amount X ________ in ____________________________________ Lot # ___________________ Expiration Date: _____________ # of punctures Physician covering contrast: _____________________________________ By ____________________________________ Power injector: Yes No Rate: _______________cc per _____________seconds Contrast reaction? Yes No Explain: _________________________________________________________________

Source: http://www.swdc-cs.com/Patient_Forms_files/MRI%20and%20CT%20SCREENING.pdf

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