MAGNETIC RESONANCE (MR) PROCEDURE …

Date _____/_____/_____ Patient Number _____ Name _____ Age _____ Height _____ Weight _____ Last name First name Middle Initial Date of Birth _____/_____/_____ Male Female Body Part to be Examined _____ month day year Address _____ Telephone (home) (_____) _____-_____ City _____ Telephone (work) (_____) _____-_____ State _____ Zip Code _____ Reason for MRI and/or Symptoms _____ Referring Physician _____ Telephone (_____) _____-_____ 1. Have you had prior surgery or an operation ( , arthroscopy, endoscopy, etc.) of any kind? No Yes If yes, please indicate the date and type of surgery: Date _____/_____/_____ Type of surgery _____ Date _____/_____/_____ Type of surgery _____ 2.

Please indicate if you have any of the following: Yes No Aneurysm clip(s) Yes No Cardiac pacemaker Yes No Implanted cardioverter defibrillator (ICD)

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