Phone: (513) 558-3882

Fax: (513) 558-1037

www.med.uc.edu/radiology

MRI PATIENT HISTORY AND SCREENING FORM

Name: Today’s Date:

Birth Date: Weight:

The following items can interfere with MR Imaging and some may be hazardous to your safety.
Please check if you have any of the following items:

No Yes
Cardiac Pacemaker
Neurostimulator/Tens Unit
Aneurysm/Artery Clips/Shunts/Stents/IVC filters
Eye Surgery (Retinal Tract/Lens Implants)
Cochlear/Stapes Implant/Shunts (Ear implants)
Renal Insufficiency
Bone/Joint/Pins/Rods/Implants
IUD (intrauterine device)
Prosthesis (Artificial Limbs/Penile Implants/Etc.)
Implanted medication pumps (Insulin/Insulin pumps)
Any metal fragments/shrapnel/bullets?
Are you pregnant? How many weeks?
Are you breastfeeding?
Have you ever had metal removed from your eyes?
Do you wear hearing aids?
Do you have tattoos? Date:
Do you have any body piercings?
Do you have any removable dental work?
Do you have any blood disorders (sickle cell disease)?
Previous brain surgery Type: Date:
Previous heart surgery Type: Date:
Previous abdominal surgery Type: Date:
Have you ever been diagnosed with any form of cancer?
Type: Date:
Treatment given:

Have you ever had any X-rays/CT/MRI for this problem in the last 3 years?
If yes, what kind? When:
Where?

Have you ever had an MRI done before?

If yes, what area of your body was scanned?
What facility was it done at?

- More information to be completed on back -

Is this exam being done due to a fall or an injury? If yes, date of injury:
Is this a work related injury?
Explain what happened?

Have you ever had surgery on the area being scanned today?
If yes, what type of surgery?
When?

Why are we doing this test today? (E.g. symptoms for doing the test)

You only need to answer the section that pertains to the exam (body part) you are having today.

Brain (head, orbits, IACs, etc.)

Where is your pain?
Any numbness? If yes, where?
Any visual disturbances (double/blurred vision)?
Any slurred speech?
Any hearing loss? If yes, which ear?
Any memory loss?
History of having strokes? If yes, when?
History of having seizures? If yes, when?
Family history of aneurysms? If yes, relationship?

Spine (cervical, thoracic, lumbar)

Where is your pain?
Any numbness? If yes, where?
Any previous back surgery? If yes, when?
What disc levels?

Extremities (knees, shoulders, hips, ankles, etc.)

Where is your pain?
Any clicking or popping?
Does it ever lock up completely?
Any decrease in the range of motion?
Is this a sports injury? If yes, explain?

Body (chest, abdomen, pelvis, etc.)

Where is your pain?
Any shortness of breath?
History of kidney stones?
Frequent urination?
Any diarrhea/constipation?

Patient Signature (or Guardian) Date

Reviewed by (Technologist) Date

Patient Care Education Research Community Service

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