MRI SCREENING QUESTIONNAIRE Patient Name: of Birth: Age: Height: Weight: Male: Female: Please describe current symptoms or problems you are experiencing (why are you having this exam): Do you have a pacemaker, lead wires or implanted defibrillator? Yes No Do you have any implanted electronic, magnetic, or mechanical devices? Yes No Have you ever had any type of surgery in the area being scanned? Yes No Have you ever had heart surgery (Pacemaker, stent, valve replacement, bypass surgery)? Yes No Have you ever had brain, eye(s), or ear(s) surgery? Yes No Do you have any implanted stents or aneurysm clips? (Please provide your stent or aneurysm card to evaluate if you are MRI safe) Yes No Do you have any external transcutaneous stimulators, pumps, or wires? Yes No Have you ever had an injury involving any metal fragments lodged in your eyes? Yes No If yes, were they removed and did a doctor tell you It s all out? Yes No Do you have any objects containing bullets, shrapnel and/or metal fragments while grinding or Yes No welding? If yes, were they removed and did a doctor tell you It s all out? Yes No Have you ever had any surgeries that required metals implanted within your body, such as metal rods, knee or hip replacements, etc. Yes No If yes, please explain. Do you have any body piercings, tattoos or tattooed permanent makeup? Yes No Are you pregnant, actively attempting to get pregnant, or nursing? Yes No If yes, please explain? Have you ever been treated for cancer? If yes, when and what type of cancer and location of body? Yes No Is this a work related injury? of injury and how? Yes No Page 1 of 6
Have you ever had a prior MRI, CT or US for the same body? If yes, when and where. Yes No WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with the MR procedure. Do not enter the MR system room or MR environment if you have any question or concern regarding an implant, device, or object. Consult the MRI Technologist BEFORE entering the MR system room. This should include anybody accompanying you such as a family member or friend. The MR system magnet is ALWAYS on. Before entering the MR environment or MR system room, you must remove all metallic objects including hearing aids, dentures, partial plates, keys, eyeglasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paperclips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners & clothing with metallic threads. In addition, please remove and turn off all mobile electronic devices, such as cell phones. You may be advised or required to wear earplugs or other hearing protection during the MR procedure to prevent possible problems or hazards related to acoustic noise. If you take any sedative, you must have a driver present upon the end of your exam. Please ensure no beauty products such as lotions, make-up, or hair spray to the area of interest that is being scanned is not worn during examination. Some beauty products or cosmetics may contain metals. Should you have any questions or concerns regarding your exam, please consult with the MR Technologist or one of our Patient Care Coordinators. Please mark on the figure(s) to the right the location of any implant or metal inside of or on your body I read and understand the contents of this form and had the opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to undergo. Patient / Responsible Party Signature If not signed by patient, print name and relationship: MRI Screening Sheet Reviewed by Technologist (Initials): Page 2 of 6
: REGISTRATION FORM Patient Information Name: of Birth: Sex: M F Address: City: State: Zip: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Social Security Number: - - Height: Weight: Check Appropriate Box: Minor Single Married Widowed Separated Divorced Name of Parent or Guardian if Minor: Emergency Contact Information Name of Contact: Phone: ( ) - Address: Relationship: Insurance Information Billing Type: Insurance Cash Workers Compensation Personal Injury Please provide insurance cards, identification, workers compensation and/or personal injury information to staff. It is your responsibility to provide us with your Insurance Company's name and address and to check with your Insurance Company to verify the portion of charges that will be covered or the requirements for any authorization or physician referral forms. We will bill your Insurance Company as a courtesy. However, you are responsible for any charges not paid by your Insurance. I understand that MRI Imaging Center, Inc and/or North West Imaging will bill my Insurance Company as a courtesy and that I am responsible for any charges not paid by my Insurance within thirty days of receipt of billing. After 30 days, collection efforts will proceed. X Signature Page 3 of 6
Patient Name: of Birth: Patient Information Sheet for Meaningful Use MRI Imaging Center of Fresno, Inc. and North West Imaging has chosen to participate in Meaningful Use. This is a Federal program signed into law in 2009 that seeks to computerize and improve the effectiveness of healthcare in the United States. This first stage involves moving healthcare providers onto computers in addition to the collection of additional patient data. You may notice this same data will be asked of you when you visit the hospital or other healthcare providers participating in the Meaningful Use mandate. If you have filled this information out and have a summary sheet from that provider, we can take a copy and save you from filling out this sheet. Please let us know if you have any questions and thank you for helping us to comply with these new government reporting measures. RACE Definitions White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American: A person having origins in any of the Black racial groups of Africa American Indian and Alaska Native: A person having origins in any of the original peoples of North, South or Central America and who maintain a tribal affiliation or community attachment Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. Native Hawaiian and Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Other Race: Includes multi-racial, mixed, interracial or a Hispanic/Latino group. Check all that apply: Preferred Language: Race: Ethnicity: English EN American Indian or Alaska Native Hispanic or Latino French FR Asian Non Hispanic or Latino Italian IT Black or African American Decline to State Chinese CH Native Hawaiian or Other Pacific Islander Japanese JA White Asian Other AO Other Race Middle Eastern ME Unknown Portuguese PO Decline to State Russian RU Spanish SP Unknown / Other UO Page 4 of 6
Medical History: Problem List (Check all that apply) Acid Reflux Cancer Leukemia Cough Hip Replacement AIDS Cancer Lung Dementia Irritable Bowel Syndrome Aneurysm Cancer Melonoma Depression Injury Asthma Cancer Pancreatic Diabetes Type 1 Kidney Stones Back Pain Cancer Prostate Diabetes Type 2 Multiple Sclerosis Body Pains Cancer Thyroid Dizziness Neuropathy Cancer Bladder Checkup Monthly Gout Obesity Cancer Breast Checkup Yearly Headache Osteoarthritis Cancer Colon & Rectal Chest Pain Hepatitis Scoliosis Cancer Endometrial Cirrhosis Hernia Sinusitis Cancer Kidney COPD High Cholesterol Tumors None Decline to State Other, please explain: Smoking Information: Current every day Former Smoker Marijuana Smoker Current some day Never Smoker Decline to State Current Medications: (Check all that apply) Advil Codein Glucophage Glucovance Aspirin Valium Fortamet Metaglip Motrin Vicodin Glumetrza ActoPlus Met Tylenol Xanax Riomet Avandamet None Decline to State Other, please explain: Medication Allergies: (Check all that apply) Codeine Penicillin Tetracycline None NSAIDS Sulfa Drugs Tylenol Other, please explain: Page 5 of 6
Authorization to Release Medical Records You are hereby authorized and directed to furnish to MRI Imaging Center of Fresno, Inc. and/or North West Imaging copies of any clinical notes and medical records prepared by you relating to the stated patient. Print Name of Birth Patient Signature Authorization for Release of Medical Records 1. I give permission to MRI Imaging Center of Fresno, Inc. and/or North West Imaging to use the following protected health information, and/or disclose the following protected health information a. Information to be disclosed (place an x in the box that apply) Medical Records (Referral form and clinical notes) Diagnostic Records (Radiologist's Report) Images (Film, Digital Media, Web Access) 2. I understand that I have the right to revoke this Authorization at any time in writing, except to the extent that MRI Imaging Center of Fresno, Inc. and/or North West Imaging has already acted in reliance to this Authorization. I can revoke this Authorization by providing a written revocation to: MRI Imaging Center of Fresno, 108 W Shaw Avenue, Fresno, CA 93704. 3. I understand that MRI Imaging Center of Fresno, Inc. and/or North West Imaging may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. 4. I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer subject to applicable privacy laws. 5. I understand that I may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, my right to access is suspended until the clinical trial is completed. This authorization shall be in force until I revoke it in writing. Print Name of Birth Patient Signature Page 6 of 6