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MRI MEDICAL HISTORY QUESTIONNAIRE Originated: Medical Record Revised: 06/09, 05/11, 03/12, 4/12 File No. RAD M13 Form No.: 10312 SET Date: / / Patient Name: DOB: Hospital Patients Only: Mode of Transportation:

How to fill out mri medical history questionnaire

How to fill out an MRI medical history questionnaire:

1. Start by carefully reading the instructions provided on the questionnaire. This will give you an overview of the information and details required.
2. Begin filling out your personal information such as your name, date of birth, and contact information. Make sure to include any alternate contact numbers if applicable.
3. Provide your medical history by accurately stating any past or current medical conditions, surgeries, allergies, and medications you are taking. It is essential to be thorough and honest in this section, as it helps the healthcare professionals to assess any potential risks or complications during the MRI procedure.
4. Answer questions related to specific conditions or symptoms that may affect your eligibility for an MRI. For example, if you have a pacemaker, cochlear implant, or if you are pregnant, responsible disclosure is crucial. This information will help determine the appropriate course of action or if any additional precautions need to be taken.
5. If you have any metal implants, tattoos, or piercings, make sure to indicate their presence and their approximate location on your body. The MRI machine uses a strong magnetic field, and these metallic objects can pose a safety risk or interfere with the scan results.
6. Sign and date the questionnaire once you have completed all the required fields. By doing so, you acknowledge that the information provided is accurate to the best of your knowledge.
7. Return the completed questionnaire to the healthcare facility or MRI center before your scheduled appointment. It is beneficial to arrive early to ensure all necessary paperwork is in order.

Who needs an MRI medical history questionnaire?

1. Patients scheduled for an MRI scan are typically required to fill out a medical history questionnaire. This is to ensure their safety during the procedure and to gather relevant information that may impact the imaging results.
2. Individuals who have previously undergone surgery, have specific medical conditions, or are taking medications that may affect the MRI scan may need to provide detailed information through the questionnaire.
3. Patients with metal implants, devices, tattoos, or piercings on or within their bodies may also be required to complete the MRI medical history questionnaire to identify any potential risks associated with these objects during the scan.
4. Pregnant women should also complete the questionnaire to inform healthcare professionals in order to take necessary precautions for their safety and the baby's well-being during the MRI procedure.
5. The MRI medical history questionnaire serves as a valuable tool for healthcare providers to gather pertinent information from patients before conducting the scan, ensuring the highest level of care and safety for each individual undergoing an MRI.

For pdfFiller’s FAQs

What is mri medical history questionnaire?

The MRI medical history questionnaire is a form used to gather information about a patient's medical history and any potential risks or contraindications related to undergoing an MRI scan.

Who is required to file mri medical history questionnaire?

Patients who are scheduled to undergo an MRI scan are required to fill out the MRI medical history questionnaire.

How to fill out mri medical history questionnaire?

Patients can fill out the MRI medical history questionnaire by providing accurate and detailed information about their medical history, current health status, and any medications they are taking.

What is the purpose of mri medical history questionnaire?

The purpose of the MRI medical history questionnaire is to ensure the safety and well-being of the patient during the MRI scan by identifying any potential risks or contraindications.

What information must be reported on mri medical history questionnaire?

Information such as medical conditions, allergies, previous surgeries, current medications, and any metal implants or devices must be reported on the MRI medical history questionnaire.

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