Rutland Form 2772 – Fill Out and Use This PDF

Outpatient MRI Order/ Prescreening Questionnaire

Upon completion, please fax to central scheduling at 776-3301.

(For Breast MRI only, fax to Breast Care Program at 747-6595.)

Patient Name: ____________________________________	Date of Birth: _______________________________
Patient Phone (8am-4pm) ___________________________	Referring Physician: _________________________
Can we leave a message?  Yes  No	Physician Signature: ________________________
(If not, please have patient call us the next business day 747-1707.)	Date and Time: ____________________________
77002 Fluoroscopy for needle placement for MR arthrogram injection		MR Arthrogram ___________
Type of MRI ordered: ________________________________ IV contrast with		 without with and without

Diagnosis/What are we looking for? _______________________________________________________________

Symptomatology/Findings: ______________________________________________________________________

YES NO PLEASE ANSWER EACH QUESTION

Does patient have a pacemaker (or pacemaker wires in chest), implantable cardiovascular device (ICD) or external device (insulin pump)?

Does patient have a brain aneurysm clip? If yes, call MRI at 747-1707 before scheduling.

Does patient have fear of close places (claustrophobia)? If yes, physician to specify minimal
or moderate sedation?	 minimal (anxiolysis)		 moderate
Is patient ≥ 60 years of age?		 Yes  No	Patient weight: __________
Is patient diabetic?  Yes		 No	Patient height: __________

If the patient is diabetic or over 60years of age a BUN and Creatinine is required (within 90 days) if patient is receiving contrast.

BUN_________ CREATININE_______ DATE________

Has patient ever had eye surgery that resulted in implants other than cataract lens?

If yes, what/when? ___________________________________________________________

Has patient ever had ear surgery that resulted in a metal cochlear implant? If yes, call MRI with type of implant. ___________________________________________

Has patient ever had an accident with metal in the eye? If yes, have they had an MRI since? If not, patient must have an x-ray before the MRI (can be done 1-2 days prior or before 5 pm on day of exam).

Has patient had any recent prior surgery, as MRIs should be done 4-8 weeks after most surgery? (If patient has had a coronary stent or Greenfield filter put in, scan must be 6 weeks postop.) Date/type of recent prior surgery: _______________________________________

Does patient have any implanted devices (other than cataract lenses)?

If yes, what? _______________________________________________________________

Is patient pregnant or think she may be pregnant? Yes No Is patient a nursing mother? Yes No

Does patient have difficulty lying flat on his/her back or stomach? If so, which?___________

ONLY FOR MRI OF BREAST:

Is patient on hormone replacement therapy (HRT)? If yes, patient needs to be off HRT for 6 weeks before MRI is performed. Date of last dose: ______________________

First day of last menstrual period: ____________ Date next period expected: ____________

MRI must be at least 6 months after end of radiation treatment; at least 1 year after end of chemotherapy.

Above portion completed by_____________________________ Date/Time _________________________

TO BE COMPLETED BY CENTRAL SCHEDULING:

MRUN: _____________ Booked by: _________ Date/Time: ________________ Confirmation #: __________

Other Exams: ___________________________________ MRI scheduled for:__________________________

FORM # 2772 REV. 03/08; 05/08, 09/08, 12/08, 5/09