Mri Screening Form printable pdf download

MRI SCREENING FORM

Patient Name: ______________________________DOB: _____________ Weight: ______________

Sex: M / F

THESE ITEMS CAN INTERFERE WITH MR IMAGING AND SOME CAN BE HAZARDOUS TO YOUR SAFTEY

Please check Yes or No to each item

Have you ever had: An injury to your eye involving metal?

YES

A metallic fragment or foreign body in your head, face, neck or body?

YES

If yes to either questions above, were you tested to ensure all metal was removed?

YES

SURGICAL IMPLANTS

YES

Cardiac Pacemaker

Aneurysm Clips

Pacemaker Wires

Neurostimulator

Electronic Implant or Device

Implanted Cardiac Defibrillator (ICD)

Spinal Cord Stimulator

Bone Fusion or Bone Growth Stimulator

Cochlear, Otologic, or Ear Implant

Tissue Expander (Breast)

Internal Electrodes or Wires

Magnetically-activated Implant or Device

Eyelid Spring or Wire

Swan-ganz Thermodilution Catheter

Cardiac Stent

Clips in Blood Vessel

Artificial Heart Valves

Implanted Drug Infusion Device/Pump

Endoscopy with Camera Pill

Venous Umbrella

Coil, Filter, Wire in Blood

Pessary or Bladder Ring

Shunt (spinal or cranial)

Any Metallic Fragment or Foreign Body

Prosthesis (Eye, Penile, etc.)

Transdermal Medication Patches (Nitro, Nicotine)

Radiation Seeds or Implants

Bone/Joint Pin, Screw, Nail, Wire, Plate, etc.

Artificial Limb, Joint Replacements

Harrington Rods (spinal)

Tens Units

Wire Mesh Implants

Vascular Access Port or Catheter

Surgical Staples, Clips or Metallic Sutures

IUD or Diaphragm

Tattoo or Permanent Makeup

Body Piercing Jewelry

Dentures or Partials

Hearing Aid

Claustrophobic

IMPORTANT INSTRUCTIONS

Before entering the MR environment or MR system room, you must remove ALL metallic objects including hearing

aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercings,

money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing

with metal fasteners and clothing with metallic threads. Consult the MRI Technologist BEFORE entering the MR

exam room if you have any questions. The MR system magnet is ALWAYS on.

Mri Screening Form

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