MRI Screening Form (Bartlett)

MRI Screening Form (Bartlett Only)

An MRI examination involves the use of a very strong magnet. For your safety, the presence of certain metallic objects must be determined before entering the exam room. If you answer yes to any implanted devices, please provide implant card and inform the MRI Technologist.

Name

OrthoSouth Physician

Gender

Weight

Age

DOB

The following items may be harmful to you during your MRI scan and may interfere with the MRI exam. Please select YES or NO answer to every item listed.

Cardiac Pacemaker / Defibrillator

Tattoos (less than 6 weeks)/Magnetic Eyelashes

Coil, Filter, Shunt, or Stent

Claustrophobia

Heart Surgery or Implant

Dentures or Partials

Artificial Heart Valve

Pregnant / Breast Feeding

Artificial Eye or Implant / Surgery

IUD or Diaphragm

If yes, please list IUD/Diaphragm type:

Neck/Back Surgery

Shrapnel/Bullets

Aneurysm Clips

Body/Ear Piercings (remove before MRI exam)

Implanted/Removable Drug Pump

Wig/Hair Implants or Hair Pins

Cochlear Implant/Ear Implant Artificial

Injury to Eye Involving Metal

Limbs/Joint Replacement

Have you ever had Cancer?

If yes, please list Cancer type.

Monitoring Device (e.g. Glucose, Libre)

Hearing Aids (remove before MRI exam)

Brain Surgery/Implants

Surgically Implanted Devices

If yes, please list type of implanted device.

Surgical Mesh

Have you recently ingested a "pill cam"?

Any Type of Internal Electrodes or Wires

Electronic, Mechanical, or Magnetic Implant

Surgical Clips or Staples

Medication Patches (e.g. nitroglycerine or nicotine)

Penile Implant

IV Access Port (e.g. Port-a-Cath, Hickman, PICC)

Stimulator (e.g. neurostimulator, deep brain, bone growth, spinal cord, etc.)

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

If yes, please list:

Please list any prior surguries and approximate dates:

Have you ever had surgery on the body part being scanned?

If yes, please describe injury:

Approximate date when pain began:

Describe your pain:

By checking the box and typing your name below, you are verifying that you have read and understand the entire content of this form.

I have read and understand the entire content of this form.

Name

Date

Form completed by:

Patient Relative Other

MRI Screening Form (Bartlett Only)

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