ADVANCED MAGNETIC IMAGING The FIRST MRI Facility in North Jersey Proudly Serving The Community Since 1985 6416 Bergenline Avenue West New York, NJ 07093-1621
MRI PATIENT QUESTIONNAIRE FieldsetLast Name First Name Middle Sex MaleFemaleHT: WT: AGE: DATE OF BIRTH: EMERGENCY CONTACT: PHONE: Instructions THE FOLLOWING ITEMS MAY INTERFERE WITH MAGNETIC RESONANCE IMAGING AND SOME CAN BE POTIENTIALLY HAZARDOUSPlease list all previous surgeries & special procedures and the approximate date? Do you have:Any type of cancer? Yes (Explains below)NoWhen: Type: A Pacemaker, Swan-Ganz catheter, or Pacing wire? YesNoA brain aneurysm clip? YesNoAn arti cial heart valve? YesNoInstructions Any other type of implanted electronic device? (Such as an insulin pump, drug infusion device, bone growth stimulator, neurostimulator, muscle stimulator or spinal stimulators.)About Above Question YesNoAn intravascular coil, lter, or stent? YesNoAny type of medicated adhesive patch on your skin? YesNoAny arti cial body parts (eyes, arms, legs, etc.)? YesNoAny bullets, BBs, or shrapnel in your body? YesNoWere you a sheet metal or lathe worker or exposed to metal silvers? YesNoHearing aid, cochlear implant or any other type of ear implant? YesNoTattooed eyeliner? YesNoAny removable dentures, partials or dental braces? YesNoAny dental item held in place by a magnet? YesNoAre your patient claustrophobic? YesNoA penile prosthesis? YesNoDi culty lying on your back for at least 30 minutes? YesNoAre you pregnant? YesNoAre you breast feeding? YesNoPlease mark on this drawing the locations of any metals inside your body. Agree *I certify that the above information is correct.Patient Signature: RT/Aide Signature: Date VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
