Magnetic Resonance (Mr) Procedure Screening For Patients Page 2
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2WARNING:
Certain implants, devices, or objects may be hazardous to you and/or may interfere with the
MR procedure (i.e., MRI, MR angiography, functional MRI, MR spectroscopy). Do not enter the MR system room
or MR environment if you have any question or concern regarding an implant, device, or object. Consult the MRI
Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS on.
Please indicate if you have any of the following:
Yes
No Aneurysm clip(s)
Please mark on the figure(s) below
Yes
No Cardiac pacemaker
the location of any implant or metal
Yes
No Implanted cardioverter defibrillator (ICD)
inside of or on your body.
Yes
No Electronic implant or device
Yes
No Magnetically-activated implant or device
Yes
No Neurostimulation system
Yes
No Spinal cord stimulator
Yes
No Internal electrodes or wires
Yes
No Bone growth/bone fusion stimulator
Yes
No Cochlear, otologic, or other ear implant
Yes
No Insulin or other infusion pump
Yes
No Implanted drug infusion device
Yes
No Any type of prosthesis (eye, penile, etc.)
Yes
No Heart valve prosthesis
Yes
No Eyelid spring or wire
Yes
No Artificial or prosthetic limb
Yes
No Metallic stent, filter, or coil
Yes
No Shunt (spinal or intraventricular)
Yes
No Vascular access port and/or catheter
Yes
No Radiation seeds or implants
Yes
No Swan-Ganz or thermodilution catheter
Yes
No Medication patch (Nicotine, Nitroglycerine)
Yes
No Any metallic fragment or foreign body
IMPORTANT INSTRUCTIONS
Yes
No Wire mesh implant
Yes
No Tissue expander (e.g., breast)
Before entering the MR environment or MR system
Yes
No Surgical staples, clips, or metallic sutures
room, you must remove all metallic objects including
Yes
No Joint replacement (hip, knee, etc.)
hearing aids, dentures, partial plates, keys, beeper, cell
Yes
No Bone/joint pin, screw, nail, wire, plate, etc.
phone, eyeglasses, hair pins, barrettes, jewelry, body
Yes
No IUD, diaphragm, or pessary
piercing jewelry, watch, safety pins, paperclips, money
Yes
No Dentures or partial plates
clip, credit cards, bank cards, magnetic strip cards,
Yes
No Tattoo or permanent makeup
coins, pens, pocket knife, nail clipper, tools, clothing
Yes
No Body piercing jewelry
with metal fasteners, & clothing with metallic threads.
Yes
No Hearing aid
(Remove before entering MR system room)
Please consult the MRI Technologist or Radiologist if
Yes
No Other implant _______________________
you have any question or concern BEFORE you enter
Yes
No Breathing problem or motion disorder
the MR system room.
Yes
No Claustrophobia
NOTE: You may be advised or required to wear earplugs or other hearing protection during
the MR procedure to prevent possible problems or hazards related to acoustic noise.
I attest that the above information is correct to the best of my knowledge. I read and understand the contents of this form and had the
opportunity to ask questions regarding the information on this form and regarding the MR procedure that I am about to undergo.
Signature of Person Completing Form: _______________________________________
Date _____/_____/_____
Signature
Form Completed By:
______________________________________ _________________________
Patient
Relative
Nurse
Print name
Relationship to patient
Form Information Reviewed By: _____________________________________ __________________________________________
Print name
Signature
MRI Technologist
Nurse
Radiologist
Other__________________________________________
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