Magnetic Resonance (Mr) Environment Screening Form For Individuals
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1MAGNETIC RESONANCE (MR) ENVIRONMENT SCREENING FORM FOR INDIVIDUALS*
The MR system has a very strong magnetic field that may be hazardous to individuals entering the
MR environment or MR system room if they have certain metallic, electronic, magnetic, or mechanical
implants, devices, or objects. Therefore, all individuals are required to fill out this form BEFORE entering
the MR environment or MR system room. Be advised, the MR system magnet is ALWAYS on.
*NOTE: If you are a patient preparing to undergo an MR examination, you are required to fill out a different form.
Date _____/_____/_____
Name ____________________________________________________
Age _______
month
day
year
Last Name
First Name
Middle Initial
Address __________________________________________
Telephone (home) (_____) _____-________
City
__________________________________________
Telephone (work) (_____) _____-________
State
____________________
Zip Code ___________
1. Have you had prior surgery or an operation (e.g., arthroscopy, endoscopy, etc.) of any kind?
No Yes
If yes, please indicate date and type of surgery: Date ____/____/____
Type of surgery________________
No Yes
2. Have you had an injury to the eye involving a metallic object (e.g., metallic slivers, foreign body)?
If yes, please describe: _____________________________________________________________________
3. Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)?
No Yes
If yes, please describe: _____________________________________________________________________
No Yes
4. Are you pregnant or suspect that you are pregnant?
WARNING:
Certain implants, devices, or objects may be hazardous to you in the MR environment or
MR system room. Do not enter the MR environment or MR system room if you have any question or concern
regarding an implant, device, or object.
an implant, device, or object.
Please indicate if you have any of the following:
IMPORTANT INSTRUCTIONS
Yes
No Aneurysm clip(s)
Yes
No Cardiac pacemaker
Yes
No Implanted cardioverter defibrillator (ICD)
Remove all metallic objects before entering the MR
Yes
No Electronic implant or device
environment or MR system room including hearing
Yes
No Magnetically-activated implant or device
aids, beeper, cell phone, keys, eyeglasses, hair pins,
Yes
No Neurostimulation system
barrettes, jewelry (including body piercing jewelry),
Yes
No Spinal cord stimulator
Yes
No Cochlear implant or implanted hearing aid
watch, safety pins, paperclips, money clip, credit
Yes
No Insulin or infusion pump
cards, bank cards, magnetic strip cards, coins, pens,
Yes
No Implanted drug infusion device
pocket knife, nail clipper, steel-toed boots/shoes, and
Yes
No Any type of prosthesis or implant
tools. Loose metallic objects are especially prohibited
Yes
No Artificial or prosthetic limb
in the MR system room and MR environment.
Yes
No Any metallic fragment or foreign body
Yes
No Any external or internal metallic object
Please consult the MRI Technologist or Radiologist if
Yes
No Hearing aid
you have any question or concern BEFORE you enter
Yes
No Other implant______________________
the MR system room.
Yes
No Other device______________________
I attest that the above information is correct to the best of my knowledge. I have read and understand the entire contents of this
form and have had the opportunity to ask questions regarding the information on this form.
Signature of Person Completing Form: ______________________________________
Date _____/_____/_____
Signature
Form Information Reviewed By: _____________________________________ ______________________________________
Print name
Signature
MRI Technologist
Radiologist
Other ______________________________
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