MAMC FORM 1527-X, 1 FEB 08 EDITION OF 1 FEB 04 WILL BE USED UNTIL EXHAUSTED. MAMC PE v1.00 1. NAME MAGNETIC RESONANCE IMAGING (MRI) PRESCREENING QUESTIONNAIRE (See Privacy Act Statement on Reverse Side.) 11. Have you Have you had plain x-rays in the last three months on the area of interest
Computed Tomography – For Patients . You may want to keep track of the number of times you receive x-rays or CT scans to avoid overexposure. Body piercing and other jewelry should also be removed it if could interfere with the test.
Low radiation x-rays pass through your body and are captured by detectors. agnosing epilepsy because it produces a very accurate representation of your brain. Also some tattoos may interfere with test as well.
Previous X-rays if yes location Female Patients: scan or may interfere with the MRI examination. You must provide a “yes” or “no” for every item. Please indicate if you ____ ____ Tattoos or tattooed eyeliner ____ ____ Radiation Seeds (e.g.,
x-Rays CT Scan MRI Scan Other Yes No When No When Yes Yes No When When Yes Yes Where Where The following items can interfere with MR Imaging, Tattoos Bullets, BBS, shrapnel Other implant
MEDICAL CONSIDERATIONS FOR PERMANENT MAKEUP, PERMANENT MAKEUP PROBLEMS, PERMANENT MAKEUP TATTOO RISKS, pictures of inside the body without using dyes or x-rays. removal for body art tattoos, even though the person had the
List previous MRI, CT, Ultrasound, X-rays or other tests related to the devices, or objects may be hazardous to you and/or may interfere with the MR procedure. Do Not Enter the MRI system room or MR environment if you have any Yes No Tattoos or permanent cosmetics Yes
x-rays: do you have a history of: ( please circle anyand all that apply) asthma seizures tumors respiratory disease heart disease stroke tattoos/ body piercings yes _____ no _____ implanted heart valves yes _____ no _____
Diagnostic Breast MRI MRI scan. Because they can interfere with the magnetic field of the MRI unit, metal and electronic objects are iodine‐based materials used for conventional x‐rays and CT scanning
Benign tumours may interfere with how the body works normally, radiation therapy is a method of delivering radiation (high energy x-rays or electrons) from outside the patient and is The tattoos are very small,