MRI Pre-Screen - Iowa Ortho

First Name *

Last Name *

Phone

Age

Date of Birth *

Height

Weight

SexMaleFemale

Physician Ordering MRI

Area to be scanned

Describe Injury or Problem

Preferred testing locationDowntown Iowa OrthoNo preferenceOther

Disclaimer

Incorrect or falsified information can cause serious injury, including blindness, burns, and/or damage to implanted items.

Have you ever had an injury to the eye involving a metallic object (e.g., metallic slivers, shavings, foreign body, etc.)YesNo

Date of eye injury

Describe injury:

Have you ever been injured by any metallic foreign body (e.g., bullet, BB, shrapnel, etc.)?YesNo

Date of metallic injury

Describe injury:

Have you ever had a surgical procedure or operation of any kind in your lifetime?YesNo

If yes, please list all prior surgeries and approximate dates:

Have you had any surgeries in the past 6 weeks?YesNo

If yes, please list:

Date

Do you have a history of cancer?YesNo

If yes, when, where, what type?

Do you anticipate any problem with lying on your back for at least 45 minutes?YesNo

Do you require assistance with any of the following: ambulation, walker, wheelchair or transferring from chair to table?YesNo

If yes, please list:

Do you have problems with claustrophobia (severe fear of small places)?YesNo

If yes, please ellaborate:

Have you ever had an MRI?YesNo

If yes, when, where, what body part?

Has the body part to be scanned ever had any of the following: x-ray, MRI, CT, or any other test?YesNo

If yes, please list:

Do you have a history of renal disease, seizure, asthma, allergic respiratory disease, diabetes, high blood pressure, anemia, or other blood disease?YesNo

If yes, please list:

Do you have any allergies to drugs or iodine?YesNo

If yes, please list:

Have you ever had a reaction to a contrast medium used for MRI?YesNo

If yes, please list:

Please indicate if you have any if the following:

The following items may be hazardous or may interfere with MRI imaging by producing artifacts.

Are you pregnant or do you suspect that you may be pregnant?Females onlyYesNo

Are you currently breast-feeding?Females onlyYesNo

Cardiac pacemaker, defibrillator or other cardiac implantIn place or removedYesNo

Aneurysm clip(s)YesNo

Spinal cord stimulator, biostimulator or neurostimulatorIn place or removedYesNo

Implanted leads or pacing wiresYesNo

Ear Surgery or Hearing implantIncluding cochlear implantYesNo

If yes, when and what type?

Any type of coil, filter, stent, or shuntYesNo

Make and model:

Picc Line, Swan-Ganz catheter or vascular access port, etc.YesNo

Any type of electronic, mechanical or magnetic implant or medication pumpYesNo

Any type of surgical hardware (plates, rods, spinal fusion, etc.)YesNo

Eye implants or surgeryLasik, Cataract, Artificial Eye, OtherYesNo

If yes, please list:

Any type of surgical clip or staplesYesNo

Drug patchYesNo

Body piercingsYesNo

DenturesYesNo

Hearing aidYesNo

Tattoos or permanent/magnetic make-upYesNoA small percentage of patients with tattoos have experienced transient skin irritation in association with MRI. Therefore, you must decide if this slight risk warrants undergoing your examination.

Any implanted birth control?YesNo

If yes, what type?

Any other type of surgically implanted medical devices, removable medical devices or personal items not covered above?YesNo

If yes, type?

If yes to any of the above, please list the physician's name, facility name, facility address, and date of implant below.

*During your MRI exam, we use noise levels that some may find unacceptable and can temporarily affect your hearing. Iowa Ortho provides headphones or ear plugs for each patient. You will also be given MRI safe clothing to change into before your exam.

Signature *

Today's Date *