Fillable Any previous reaction to MRI OR CT Contrast/Dye

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Any previous reaction to MRI OR CT Contrast/Dye

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File type: PDF

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PT NAME:
DOB:
GENDER:
HEIGHT/WEIGHT:
229 Clearfield Avenue, Ste. 100 Virginia Beach, VA 23462
1554 River Birch Run North Chesapeake, VA 23320
4668 Pembroke Boulevard, Ste. 109 Virginia Beach, VA 23455
EXAM DATE:
TIME:
PM
MRI/CT SCAN:
LEFT
RIGHT
BILATERAL
ADDITIONAL SCANS
:
LEFT
RIGHT
BILATERAL
PREP:
*SYMPTOMS:
HOW LONG:
SNAPPING/POPPING
YES
NO
VISION LOSS
YES
NO
SYNCOPE/BLACKOUT
YES
NO
HEADACHE
YES
NO
PAIN/RADIATING PAIN
YES
NO
DIZZINESS
YES
NO
SWELLING/EFFUSION
YES
NO
MASS/LUMP
YES
NO
NUMBNESS/TINGLING
YES
NO
HEARING LOSS
YES
NO
LIMITED/DECREASED RANGE OF MOTION
YES
NO
ABNORMAL FINDINGS (Labs, Imaging, Test results)
YES
NO
ABNORMAL GAIT (Step/Walk)
YES
NO
**ANY OTHER SYMPTOMS NOT LISTED:
USING A WALKER/WHEELCHAIR/CANE/CRUTCHES?
YES
NO
NEED ASSISTANCE ON/OFF TABLE OR GETTING DRESSED?
YES
NO
CURRENTLY ON AN OXYGEN DEVICE? *NEED 50FTTUBE*
YES
NO
CLAUSTROPHOBIC
?
Type of Sedative?
YES
NO
*SAFETY CLEARANCE*
PACEMAKER
YES
NO
STIMULATOR/DEFIBRILLATOR
YES
NO
STENTS/FILTERS/COILS/SHUNTS
YES
NO
PROSTHETIC HEART VALVE
YES
NO
COCHLEAR/EAR IMPLANT/HEARING AID
YES
NO
INFUSION PUMP/DRUG INFUSION DEVICE
YES
NO
SURGICAL CLIPS/STAPLES/WIRES
YES
NO
ELECTRONIC IMPLANT/DEVICE
YES
NO
BREAST TISSUE EXPANDERS
YES
NO
ORTHOPAEDIC HARDWARE
YES
NO
MEDICATION PATCHES
YES
NO
BODY PIERCINGS/JEWERLY
YES
NO
BRACES/DENTURES
YES
NO
TATTOOS/PERMANENT MAKE-UP
YES
NO
PROSTHESIS (EYE, PENILE)
YES
NO
CURRENT IUD/PREGNANCY-ARE YOU NURSING?
YES
NO
PREVIOUS MACHINIST, LATHE/METAL WORKER, WELDER
YES
NO
EVER HAD AN EYE OR METAL FRAGMENT INJURY
YES
NO
(BB'S/PELLETS/SHRAPNEL)
**NEEDS CLEARANCE:
PLEASE CALL MRI & CT AT 671-1144 EXT 3 IF
YOU HAVE HAD ANY SURGERY, IMPLANTS,
STENTS OR METAL IN YOUR BODY BEFORE YOUR
APPOINTMENT
* CONTRAST ONLY:
Any previous reaction to MRI OR CT Contrast/Dye or IVP?
IF YES, PLEASE DESCRIBE:
YES
NO
MULTIPLE MYELOMA (CANCER IN PLASMA CELL)
YES
NO
MYASTHENIA GRAVIS (AUTOIMMUNE NEUROMUSCULAR DZ)
YES
NO
GRAVES DISEASE (OVERACTIVE THYROID GLAND)
YES
NO
HYPERTENSION (HIGH BLOOD PRESSURE)
YES
NO
DIABETES-MEDICATION:
YES
NO
CURRENTLY ON DIALYSIS **MUST HAVE SAME DAY**
YES
NO
KIDNEY DISEASE/FAILURE/TRANSPLANT
YES
NO
KIDNEY REMOVED - HOW LONG AGO:
YES
NO
ALLERGY TO LATEX
YES
NO
HIV/AIDS
YES
NO
ASTHMA
YES
NO
HISTORY
HISTORY OF HEART DISEASE
YES
NO
HISTORY OF LIVER DISEASE AND/OR TRANSPLANT
YES
NO
HISTORY OF CANCER
YES
NO
IF YES, TYPE OF CANCER:
CURRENTLY RECEIVING OR HISTORY OF CHEMOTHERAPY
TREATMENTS, RADIATION TREATMENTS, RADIATION SEEDS OR IMPLANTS
YES
NO
*The information provided in this questionnaire is true
and complete to the best of my knowledge. I understand
that the accuracy of the information I have provided is
important to MRI &. CT Diagnostics ability to provide the
best possible medical care. Your signature below
indicates you have read and understand the entire
contents of this form and have had the opportunity to ask
questions regarding the requested information. Thank
you.
Sign:
Date:
F/UAPPT:
FILM
CD
ONLINE
NONE
*lnjury/Accident/Trauma?
DOI:
*Medication?
Length of Each
*Therapy? How Long?
When/Where?
*Prior Scans to this area of the body?
When/Where?
* Prior Surgery to this area of the body?
When/Where?
* Prior Surgery to abdominal area? (removal of gallbladder, appendix, or
a prior hysterectomy, c-section, etc.)
SCHEDULER
RECEPTIONIST
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Any previous reaction to MRI OR CT ContrastDye

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Completed 16 December 2020

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