Cti Safety Assessment Form For Mri Machines

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CTI SAFETY FORM
MRI MACHINES USE A VERY STRONG MAGNET TO GENERATE IMAGES. CERTAIN IMPLANTS, DEVICES OR
OBJECTS MAY BE HAZARDOUS TO YOU AND/OR MAY INTERFERE WITH THE MR PROCEDURE. BEFORE
ENTERING THE MRI ROOM YOU MUST REMOVE ALL METALLIC OBJECTS.
GFR VALUE > 60 _______
DATE ________
PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:
CARDIAC PACEMAKER
ARE YOU PREGNANT
YES
NO
YES
NO
IMPLANTED CARDIAC
ELECTRONIC DEVICE (DEEP
YES
NO
YES
NO
DEFIBRILLATOR (ICD)
BRAIN/SPINAL CORD/NERVE
STIMULATOR
INTERNAL
INJURED EYES WITH METAL
YES
NO
YES
NO
ELECTRODES/WIRES
FLAKES/SLIVERS/SHRAPNEL
ARE YOU CLAUSTROPHOBIC
EYELID SPRING OR WIRE
YES
NO
YES
NO
COCHLEAR IMPLANTS
MAGNETIC IMPLANTS
YES
NO
YES
NO
SWAN-GANZ OR THERMO-
YES
NO
DILUTION CATHETERS
IF YES ANSWERED TO ANY OF THE ITALICIZED BOLD PRINT QUESTIONS SUBJECT IS NOT ELIGIBLE FOR MR
BONE FUSION STIMULATOR
EAR SURGERY
YES
NO
YES
NO
TISSUE EXPANDER
HEAD SURGERY
YES
NO
YES
NO
EYE SURGERY
HEARING AID
YES
NO
YES
NO
HEART VALVE PROSTHESIS
TENS UNIT FOR PAIN
YES
NO
YES
NO
INSULIN OR DRUG INFUSION
RADIATION SEEDS OR
YES
NO
YES
NO
DEVICE
IMPLANTS
VASCULAR ACCESS PORT
WIRE MESH IMPLANTS
YES
NO
YES
NO
SHUNTS AND/OR STENTS
WORKED WITH METAL
YES
NO
YES
NO
BODY PIERCING JEWELRY
VASCULAR SURGERY
YES
NO
YES
NO
ANEURYSM CLIP (S)
IUD/DIAPHRAGM/PESSARY
YES
NO
YES
NO
BONE/JOINT PIN, SCREWS,
TATOO/PERMANENT MAKE
YES
NO
YES
NO
PLATE etc…
UP
OTHER FOREIGN BODIES OR
JOINT REPLACEMENT OR
YES
NO
YES
NO
IMPLANTS
PROSTHETIC IMPLANTS
SURGICAL STAPLES OR CLIPS
DENTURES OR PARTIALS
YES
NO
YES
NO
MEDICATION OR NICOTINE
DO YOU HAVE KIDNEY
YES
NO
YES
NO
PATCH
DISEASE
DO YOU HAVE ASTHMA OR
ARE YOU ALLERGIC TO ANY
YES
NO
YES
NO
OTHER RESPIRATORY
DRUGS, MRI OR CT
DISEASE
CONTRAST
DO YOU HAVE SICKLE CELL
HAVE YOU EVER HAD AN
YES
NO
YES
NO
ANEMIA
ALLERGIC REACTION
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE PLEASE EXPLAIN: _________________
______________________________________________________________________________________
______________________________________________________________________________________
SUBJECTS NAME_________________________________SIGNATURE________________________
(PLEASE PRINT)
BIRTHDATE____________ WEIGHT____________HEIGHT_____________DATE______________

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