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MRI Patient Questionnaire
Patient Information
Name
*
Date of Birth
*
Year
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Physician
*
Current Weight
*
Questions
Please answer these carefully. The following items may be hazardous or may interfere with the MRI examination by producing an artifact. Please indicate if you have the following:
Cardiac (heart) pacemaker or wires?
*
Yes
No
Cardiac Monitor?
*
Yes
No
Prosthetic heart valve?
*
Yes
No
Aneurysm clips?
*
Yes
No
Are you on any type of oxygen?
*
Yes
No
Implanted neurostimulator unit (TENS)
*
Yes
No
Any type of biostimulator?
*
Yes
No
If yes, type?
Swan_Ganz Catheter
*
Yes
No
Any type of intravascular coil, filter, stent?
*
Yes
No
(i.e. Cianturco coil, Gunter IVC Filter, Palmaz stent, etc.)
If yes, type?
Any implanted orthopedic items?
*
Yes
No
(i.e. pins, nails, clips, plates, wire, etc)
Penile prosthesis?
*
Yes
No
Orbital/eye prothesis?
*
Yes
No
Any history of asthma, bronchitis, or emphysema?
*
Yes
No
Middle ear prosthesis or cochlea implant?
*
Yes
No
Known or possible metal fragments in the eye, head, or body?
*
Yes
No
(attn: welders, machinists, metal workers, etc.)
Are you pregnant
*
Yes
No
Any type of implant held in place by magnet?
*
Yes
No
(i.e. dentures)
If yes, type?
Vascular access port?
*
Yes
No
Artificial limb or joint?
*
Yes
No
Inflatable breast implant
*
Yes
No
IUD?
*
Yes
No
Permanent tatto, permanent eyeliner?
*
Yes
No
Hearing aid?
*
Yes
No
Any type of medication patch?
*
Yes
No
Pain pump?
*
Yes
No
Other
Do you have any other medical problem?
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.
Full Name
*
Date
*
Year
Year
2024
Month
Month
Oct
Day
Day
4
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