Advanced Medical Imaging

Patient History Form for MRI Screening

Please complete the following form before your MRI with AMI.

PATIENT INFORMATION
Appointment Date:		Name		Date of Birth
Phone (Home)		Phone (Work)		Phone (Cell)
Address		City, State		Zip
Emergency Phone		Gender	M F	Weight
Email:
PATIENT HISTORY
Check all of the following that apply
Yes No	Cardiac pacemaker/implanted defibrillator or wires
Yes No	Brain aneurysm clips
Yes No	Neurostimulators
Yes No	Vagus Nerve Stimulator
Yes No	Diabetic insulin pump
Yes No	Electrodes or Implanted Stimulator
Yes No	Hearing aid
Yes No	IUD
Yes No	Shunt
Yes No	Fractured bones treated with metal rods, plates, pins, screws, nails or clips
Yes No	Prosthesis (i.e. artificial limb)
Yes No	Shrapnel or bullets
Yes No	Dentures
Yes No	Penile prosthesis
Yes No	Metal in eyes
Yes No	Ear surgery
Yes No	Pregnant of breast feeding
Yes No	Medicinal patches
Yes No	List Allergies