Side 2 of 2. MRI Screening Questionnaire MRN #: MRN# DOB: Patient Name: Date: Provider: 2 . There is some general information about the patient and the MRI that was ordered at the top left portion of the page. vdrive/forms/mri/mri patientscreeningform/updated 8/9/2019 mri screening form name: _____ d.o.b:___/___/___ age: ____ sex: m / f MRI Safety Screening Questionnaire MRI, unlike other methods of imaging the body, does not use radiation but rather uses magnetism and radio waves. This strong magnetic field has the potential to harm individuals with certain medical implants and/or conditions. When an MRI is ordered, a task will appear on the worklist to complete the MRI Screening Form. MRI PATIENT SCREENING QUESTIONNAIRE If you answered YES to any of the questions on the front page, please discuss any concerns and/or issues you may have, with your MR … It is important that you answer all of the following questions. It will be the responsibility of the MRI technologist to review the MRI screening … 6. MR Safety continues to evolve and in response, the ACR's Committee on MR safety created the ACR Manual on MR Safety with updates and critical new information which replaces all earlier … cardioverter defibrillator (ICD) Electric device or implant YES NO … The introduction of certain metallic objects into the magnet area also has ... MRI Screening Questionnaire … mri patient screening questionnaire and consent form . Form # 819 Created 5/2020 . MRI Worker Screening Form ... An MRI instrument produces a strong magnetic field that is ALWAYS ON. Are you allergic to any … When ready to complete the form, click . CBI MRI Screen Version 050120 MRI Metal Screening Questionnaire Must be completed on the day of the scan Sub ID/Name: _____ Age _____ Height _____ Weight _____ Instructions: The following items may be harmful in the scanner or may interfere with the MRI … Extensive evaluation has shown no long … 9 Yes 9 No 8. Are you breastfeeding? Patient Screening Patients entering an MRI suite for a diagnostic exam are screened for the contraindications discussed above. 9 Yes 9 No 7. This questionnaire is designed to assist us in determining if it is safe for you to undergo a magnetic resonance imaging procedure. MRI SCREENING QUESTIONNAIRE 17163 0907 ESI# 138233 *17163* ˜˚˜˛˝ Community Hospitals of Indiana, Inc. ˜ Community Hospital East ˜ Community Hospital North ˜ Community Hospital South ˜ Community Imaging Center OUTPATIENT MRI QUESTIONNAIRE … 2. A standard hospital approved MRI screening form is to be filled out prior to a patient entering Zone 3/4. Are you pregnant or possibly pregnant? If you don’t understand any question, ... MRI Screening Questionnaire … MAGNETIC RESONANCE IMAGING (MRI) QUESTIONNAIRE. surname first name date of birth chi height weight ... i understand the mri examination. Below that is the screening … The screening form will open up. i also understand the above questions and …

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