MRI Procedure Screening Form

Genesis Health System

* Denotes required fields
Due to strict safety requirements, ALL patients are required to be screened upon each MRI exam.

THE FOLLOWING ITEMS MAY BE HAZARDOUS OR INTERFERE WITH THE MRI EXAM BY PRODUCING AN ARTIFACT OR MORE IMPORTANTLY, CAUSE INJURY TO YOU.
* 1. Do you have a cardiac pacemaker, pacing wires or defibrillator?
* 2. Have you ever performed ANY metal work (welding, grinding, drilling)?
* 3. Have you had any surgery or procedure within the last 2 months?

Surgery History

* 4. Brain Surgery?
* 5. Implanted devices?
* 6. Implanted Neuro or Biostimulators?
* 7. Intraventricular Shunt?
* 8. Swan-Ganz Catheter? (This is a pulmonary artery catheter, not a urinary catheter)
* 9. Vascular Access Port?
* 10. Previous Heart Surgery?
* 11. Intravascular Coil, Filter?
* 12. Any type of eye surgery?
* 13. Any type of ear surgery?

Additional Information

* 14. Do you require a hearing aid?
* 15. Any chance you could be pregnant?
* 16. Any type of prosthesis?
* 17. IUD / Diaphragm?
* 18. Any implanted metallic items?
* 19. Gunshot or shrapnel injury?
* 20. Transdermal Medication Patch
* 21. Body piercings?
* 22. Tattoos?
* 23. Are you claustrophobic?

MRI History

Previous Exams Outside of Genesis

* MRI:
* CT:
* Nuc Med Bone Scan:
* Plain Film X-Ray:
* Prior Contrast Reaction:
* History of Asthma:
* History of Sickle Cell:
* History of Liver Transplant:
* History of Kidney Transplant:
* History of Kidney Disease:
Lab work in the last 6 weeks? Answer only if you are having an exam with contrast or you are over the age of 60.
* History of Cancer?

Contact Us

To schedule, please call:

563-421-XRAY (9729)

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