Fox Valley Orthopedics Geneva North 2535 Soderquist Court, Geneva, IL

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FOX VALLEY ORTHOPEDICS 2525 KANEVILLE ROAD GENEVA, IL 60134 630-584-1400 2535 SODERQUIST COURT GENEVA, IL 60134 630-584-1400 1975 LIN LOR LANE, PLAZA SUITE, ELGIN, IL 60123 847-468-1400 PREPARING FOR

A painless, diagnostic imaging test, an MRI (magnetic resonance imaging) aids in the evaluation of injuries and/or disease in various areas of the body: Images of organs, soft tissues, bone, and

1 FOX VALLEY ORTHOPEDICS 2525 KANEVILLE ROAD GENEVA, IL SODERQUIST COURT GENEVA, IL LIN LOR LANE, PLAZA SUITE, ELGIN, IL PREPARING FOR YOUR APPOINTMENT Location Fox Valley Orthopedics Geneva North 2535 Soderquist Court, Geneva, IL What is an MRI? A painless, diagnostic imaging test, an MRI (magnetic resonance imaging) aids in the evaluation of injuries and/or disease in various areas of the body: Images of organs, soft tissues, bone, and other internal structures are obtained using high-powered magnetic fields, low frequency radio waves, and computers. Once the images have been interpreted by a radiologist, a report is sent to your physician so that an optimal treatment plan can be customized for you. We strive to make your MRI a positive and comfortable experience. Our large MRI exam room has floor to ceiling windows that allow in plenty of natural light. We offer noise reducing headphones with your choice of music to create a calming atmosphere. High Field MRI and Safety Unlike an X-ray, MRI technology doesn t use harmful ionizing radiation. However, it isn t safe to enter the MR environment with certain metallic, electronic, magnetic, or mechanical implants, devices, or objects. Please let our MRI staff know if any of the following applies to you: Cardiac pacemaker or implantable defibrillator Brain aneurysm clip(s) Heart implants and heart stents Electronic implants or devices (such as a drug pump or neurostimulator) Cochlear (inner ear) implants Catheter that has metal components Bullets, shrapnel, or other type of metal fragments Pregnant

2 Patient MRN MAGNETIC RESONANCE IMAGING PATIENT HISTORY FORM Date of MRI exam: Patient Name: Date of Birth: / / Age: Height: Weight: MRI Exam(s) Check all symptoms that apply to the reason you are being examined today : Pain Weakness Head exams: Swelling Locking of joint Dizziness Bruising Clicking/Popping Headache Mass/lump Loss of bladder function Hearing loss R/L Numbness Tingling Ringing in ear(s) Blurred vision NO Are your symptoms a result of an accident or known injury? If yes, describe how your accident or injury occurred Briefly describe your symptoms (sharp, dull, achy) and location How long have you had your symptoms? NO Steroid injection in the area to be examined? Last injection date NO Surgery in the area to be examined? Date of surgery NO Have you been diagnosed with arthritis? NO Do you have a History of Cancer? Type When If yes, Did you receive chemotherapy? NO Did you receive radiation therapy? NO Brain or Neck exams only : NO History of seizures Last seizure Date NO History of stroke When NO Diagnosed with multiple sclerosis When Contrast Safety contrast studies only: NO Have you had an adverse reaction or allergy to imaging contrast (dye). If yes, CT or X ray contrast MRI contrast NO Have you had an adverse reaction to Adhesives Lidocaine Betadine? Check those that apply NO Do you have high blood pressure or take medication to control high blood pressure? NO Do you have Diabetes Mellitus? NO Do you have a history of having a kidney transplant or surgery, or do you have a single kidney? NO Have you been diagnosed with kidney cancer? NO Have you had Chemotherapy in the last 3 months? Technologist scanning notes: Physician Notes were not available at time of exam/reading. Please compare with previous MRI Xray CT Bone Scan Other

3 Patient MRN MAGNETIC RESONANCE IMAGING (MRI) PROCEDURE SCREENING Level2 Name: (Please Print) Last First Certain implants, devices or objects may be hazardous to you and/or may interfere with the MRI procedure. Do Not Enter the MRI scan room if you have any questions or concerns regarding an implant, device, or object. Always consult with the MRI Technologist BEFORE entering the MRI scan room. Please check yes or no in the following list and any device(s) you have: NO Cardiac Pacemaker or Implanted cardiac defibrillator (ICD) NO Brain Surgery with or without [plate(s), Aneurysm clip(s), intraventricular shunt or valve] NO Shunt or Shunt Valves [spinal or intraventricular (brain)] NO Heart Surgery [Bypass, Artificial heart valve, occluders] NO Stent of any type [Cardiac, Biliary, Ureters/Kidney] Location: NO Internal or external electrodes or wires (pacer wires) NO Ear Surgery [Cochlear implant or any type of inner ear implant] NO Vascular Filter, Coil, Graft Location: NO Neurostimulator or Biostimulator Location NO Electronic or mechanical implant [ie: tens unit] NO Drug pump (insulin, chemo, Baclofen, pain) Removable? NO Eye Surgery [lens implant from cataract removal, artificial eye, eye lid spring, or glaucoma shunt etc.] NO Eye injury involving Metal [metal slivers, shavings or fragments] Date of injury NO Spinal Hardware [Fixation device, Spinal fusion procedure plates, screws, Halo vest] NO Artificial limb Location(s) NO Joint Replacement or Orthopedic Hardware [pins, rods, screws, anchors, nails, plates, wires] Location(s) NO Endoscopy or Colonoscopy within the last 6 weeks Were clips placed? NO NO Metal Surgical Clips, Sutures, Staples or Hernia Mesh Location(s): NO Radiation Seeds [e.g. cancer treatment] Location NO Catheters or IV Access Port Location NO Any implants held in place by a Magnet [eye, dental, stoma, valve] Location NO Any other type of Implanted Item List NO Retained Metal Foreign Object [e.g. shrapnel, bullet, BB, pellets] Location NO Medication patch [e.g.nitroglycerine, nicotine, hormone] Y N Removable NO Dentures, false teeth or partial plates Removable? NO Tattoo(s), permanent makeup, eyeliner, or eyebrows Location NO Non removable Body Piercing or Jewelry Location NO Wig, Hair Extensions or Hair Implants [including eyebrows] NO Hearing aid [Remove before entering MR room ] Male Patients: NO Penile Implant Female Patients: Date of last menstrual period: / / Peri menopausal Post menopausal NO Are you pregnant or suspect that you could be pregnant? NO IUD, diaphragm, or pessary currently in place? NO Breast Surgery [Implant, Tissue Expander, surgical clip] Before entering the MR scan room, you must remove ALL metallic and electronic objects. [Hair accessories, Jewelry,Watches, Clothing with metal fasteners or metallic threads, drug pump, steel toed footwear, coins, bank cards] *I attest that the above information is correct to the best of my knowledge and have informed the MRI Staff of my surgical history before entering the MRI scan room. I read and understand the contents of this form and had the opportunity to ask questions. *Patient or Legal Guardian s Signature Date Relationship (if not the patient)

4 Patient MRN MAGNETIC RESONANCE IMAGING PATIENT HISTORY FORM Date of MRI exam: Patient Name: Date of Birth: / / Age: Height: Weight: MRI Exam(s) Check all symptoms that apply to the reason you are being examined today : Pain Weakness Head exams: Swelling Locking of joint Dizziness Bruising Clicking/Popping Headache Mass/lump Loss of bladder function Hearing loss R/L Numbness Tingling Ringing in ear(s) Blurred vision NO Are your symptoms a result of an accident or known injury? If yes, describe how your accident or injury occurred Briefly describe your symptoms (sharp, dull, achy) and location How long have you had your symptoms? NO Steroid injection in the area to be examined? Last injection date NO Surgery in the area to be examined? Date of surgery NO Have you been diagnosed with arthritis? NO Do you have a History of Cancer? Type When If yes, Did you receive chemotherapy? NO Did you receive radiation therapy? NO Brain or Neck exams only : NO History of seizures Last seizure Date NO History of stroke When NO Diagnosed with multiple sclerosis When Contrast Safety contrast studies only: NO Have you had an adverse reaction or allergy to imaging contrast (dye). If yes, CT or X ray contrast MRI contrast NO Have you had an adverse reaction to Adhesives Lidocaine Betadine? Check those that apply NO Do you have high blood pressure or take medication to control high blood pressure? NO Do you have Diabetes Mellitus? NO Do you have a history of having a kidney transplant or surgery, or do you have a single kidney? NO Have you been diagnosed with kidney cancer? NO Have you had Chemotherapy in the last 3 months? Technologist scanning notes: Physician Notes were not available at time of exam/reading. Please compare with previous MRI Xray CT Bone Scan Other

5 Patient MRN MAGNETIC RESONANCE IMAGING AUTHORIZATION FORM A Magnetic Resonance Imaging (MRI) exam requires you to lie on a movable table which is slowly guided into the center of a large cylinder. MRI uses powerful magnetic fields, radio waves, and a computer to acquire detailed pictures of your body s internal structures. During your exam, you will hear loud knocking noises and will be provided hearing protection. Benefits of MRI: Painless and non invasive Uses no ionizing radiation Provides excellent images of soft tissue and bony structures Risks of MRI: The magnet is always on and has the potential to cause physical injury if loose metal is taken into the scan room. All loose metal, such as hair pins, will need to be removed and left within the provided locker in the changing room. There are instances when MRI may be hazardous to an individual. These include the presence of certain brain aneurysm clip(s), a cardiac pacemaker or defibrillator, a heart implant, an electronic stimulator, an ear or eye implant, an implanted drug pump, metal fragments in or near the eyes, or shrapnel, bullets, and pellets within the body. If you are pregnant or suspect that you could be pregnant, please notify the technologist before your exam. For your safety, it is important that you inform the MRI technologist of your surgical history and any prior injuries with metal before entering the MRI scan room. MRI Contrast Injection Risks : In some cases, a contrast material called gadolinium may be injected into your vein to gain more information. The injection may cause minor pain, bruising and/or infection at the injection site. Allergic reactions are extremely rare (less than 1%). Reactions can range from minor hives and sneezing to more serious life threatening reaction. Gadolinium does not contain iodine. If you have severe kidney failure and receive gadolinium, you may develop a rare disease called Nephrogenic Systemic Fibrosis (NSF). Symptoms of NSF include thickening and tightening of the skin and scarring of organs. This disease is not curable and may be life threatening. Please note that NSF has not been reported in individuals with normal kidney function. Please notify the technologist if you have allergies to contrast materials (imaging dye) kidney or are pregnant or nursing. I have read this form in its entirety and fully understand it. I have had the opportunity to ask questions concerning the MRI exam and the risks involved. I hereby give authorization and consent to the MRI study. Signature of Patient Date Signature of Legal Guardian, or Representative plus relationship Date I do not consent to a Gadolinium contrast injection. Patient initials Witness Date

6 FOX VALLEY ORTHOPEDICS 2525 KANEVILLE ROAD GENEVA, IL SODERQUIST COURT GENEVA, IL LIN LOR LANE, PLAZA SUITE, ELGIN, IL NOTICE TO MEDICARE, MEDICAID, AND TRICARE PATIENTS Your physician has ordered an MRI for further diagnosis of your condition. Fox Valley Orthopedic Institute has a 1.5 Tesla MRI unit which holds the American College of Radiology (ACR) Accreditation standard. MRI exams are interpreted by dedicated, specially trained musculoskeletal radiologists. The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and requires that we provide you a list of other MRI suppliers that are free standing or in physician offices. You are free to obtain your MRI at any outside facility you choose. is not affiliated with the facilities listed below and is unable to endorse or guarantee the quality of care they provide. Please check with your medical insurance carrier(s) as these facilities may not be covered by your insurance plan(s). Local High-Field ACR Accredited MRI Facilities Naperville Fox Valley Imaging Center 1971 Gowdy Road, Suite 107 Naperville, IL Phone: Midwest Center for Advanced Imaging 4355 Montgomery Road Naperville, IL Phone: Aurora Dreyer Medical Clinic 1221 N. Highland Ave. Aurora, IL Phone: Wheaton Community Imaging of Dupage 270 West Loop Road Wheaton, IL Phone: Yorkville Midwest Center for Advanced Imaging 88 W. Countryside Parkway Yorkville, IL Phone:

MRI Patient Screening and History

Griffin Imaging, LLC Fax:: (770) 229-4632 Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT NAME: AGE: WEIGHT: SEX: MALE FEMALE REFERRED BY DOCTOR: