Dr. Cantrell Medical Information Sheet

MRI Screening Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Appointment*

MonthDayYear
Date
Time of Appointment*

:HourMinutesAM/PM Option
Physician*
Age*
Weight*
Height*
Body Part*
History 1

Please indicate if you have any of the following in your body
*Please call 214-222-6662 if you select yes to any questions in this History 1 section.
Programmable Shunt
Pacemaker/Wires
Internal Defibrillator
Cardiac implant device monitor
Stimulator/Wires
Epidural/Swam Ganz Catheter
Tissue Expander
Surgical Clips
Cardiac Stent
Blood Vessel Coil
Aneurysm Coil
Cochlear Implant/Ear Implant
Tracheostomy
IVC Filter
Penile Prosthesis
History 2

Please indicate if you have any of the following in your body
Hearing Aid
IUD
Eye Implants
Bullets, BBs, Pellets
Medication Patch
Nicotine Patch
Artificial Limb
Infusion Pump
History of Facial Injury
Pregnant or Breastfeeding
Date of last menstrual period

MonthDayYear
Date
Other implanted metal or devices:
Please list all surgeries you have had and their respective dates.
I attest that the above information is correct. I have read and understand the content of this form and had the opprotunity to ask questions regarding the information on this form, for the MRI procedure that is about to be performed.
Name of person completing the form*
Relation to the patient*

SelfSpouseParentChildOther
Signature*

Clear
Should be Empty:

MRI Screening Form