EFTA00313609.pdf

A1/4. The Mount Sinai Hospital Name: J er-Fizei L-Ps-re i,..1 Mount One Gustave L. Levy Place siraii New York, New York 10029 008: kL/aS 19 53 Gender& F Doctors MRN: DEPARTMENT OF RADIOLOGY MAGNETIC RESONANCE IMAGING (MRI) Location: PATIENT SCREENING Physician: QUESTIONNAIRE your eligibility for an INSTRUCTIONS: Please answer each question below. Your responses will allow us to determine MRI scan Each box should be marked individually— plPacs, do not simply draw a line down a column. Yes No 0 Q 1. Do you have a pacemaker. AICD, internal pacing wires, EKG leads or Hotter monitor? 0 Ll 2. Have you had brain surgery or do you have metallic clips (aneurysm clips) in your head? or 0 C? 3. Do you have an implanted stimulator (including bone growth stimulator, spinal stimulator cochlear or other ear Implant) cr medication infusion pump? El el 4. Have you ever had eye surgery or implants? E, to 6. Have you ever worked around a metal lathe. had metal shavings or fragments in your eye(s). or had a shrapnel (war or gunshot) injury anywhere in your body? I vessels? o If] 6. Have any devices (e.g.. stern, filter, coil or vascular port/catheter) been placed in your blood o p 6a. If you do have a stent, is a drug-eluting? 0 0 7. Do you have an implanted tissue expander? • 0 8. Do you have a replaced heart valve, other prosthesis or any other surgical implant? 0b 9. Do you have any tattoos, permanent make-up, or piercings? 0 b 10. Do you wear hearing aid(s), either in the ear canal or on the surface? (Remove before entering room) 0 m 11. Do you wear a transdermal medication patch (e.g., Nitroglycerin. Nicotine, etc.)? 0 O LJ 12. Do you have kidneyrrenal disease. liver disease, or diabetes? o q 13. Do you have any allergies? If so, speefy: 0 li 14. Are you claustrophobic (afraid of enclosed or tight spaces)? o Ili 16. Are you wearing a RFID or Radiofrequency ID device (commonly a wristband on an inpatient)? 0 0 16. If female, are you (or could you be) pregnant or are you breastfeeding? 17. List any other type of metal in or on your body: 18. Patent age: > years ( (pounds) and patient height (feet-inches) 19. Approximate patient weight II J WARNING: Do not enter the MR system room or MR environment if you have any question or A concern regarding an implant, device or object. Consult the MRI Technologist or Radiologist BEFORE entering a MR system room. The MR magnet Is ALWAYS on. a Physician irrfratient 20. Please Print name, -J-eff-;ge•I eiqsn-r),..1 PRINTED NAME o Relative a Other. sign, date and time 2 / i 6 - /aCI (-- SIGNATURE -------NN DA'E 'JUL RFID removed s Yes z No ( ) N/A DATE / / FOR COMPLETION TIME BY MRI TECH SIGNATURE WU TECHNOLOGIST PERSONNEL DATE / / REVIEWING FORM ATM NURSE NURSE SIGNATURE TIME 6117114 EFTA00313609