Research Participant Medical History and Safety Screening
[pic] Biomedical Imaging Center
Beckman Institute for Advanced Science and Technology
University of Illinois at Urbana-Champaign
Minor Research Participant Medical History and Safety Screening
Please answer ALL of the following questions:
Date: ____________ Name: __________________________________________________
Female Male Age: _____ Date of birth: ________ Height: ft.__ in.__ Weight____
Handedness: Right Left E-mail: _________________ Phone: (____)____-________
Certain items or conditions can interfere with MR imaging quality or present a safety hazard in an MR environment. Please check if you have any of the following items: (must check each question with a “Yes” or “No” response)
Basic History Yes No
1. Have you ever had an MRI before? If yes, which part(s) of the body were scanned? ____________________________________________________
2. Have you ever been scanned at the Biomedical Imaging Center before? If yes, please provide approximate date and/or study.
_____________________________________________________
3. Have you ever experienced any problem related to an MRI examination or MRI procedure? If yes, please describe: __________________________________________________________________________________________________________
4. Are you claustrophobic?
5. Have you ever had a surgical operation, or procedure of any kind?
If yes, please list all prior surgeries and the approximate year of each:
______________________________________________________
______________________________________________________
6. Are you allergic to animal dander?
7. Is there any chance that you could be pregnant?
**Please inform the technologist if you suspect that you could be pregnant.**
Chest Yes No
8. Do you have a cardiac pacemaker?
9. Do you have an implanted cardioverter defibrillator (ICD)?
10. Do you have aortic clips?
11. Have you had open heart surgery?
12. Do you have any staples, clips, or wire sutures?
13. Do you wear a transdermal patch (nicotine or nitroglycerin)?
14. Do you have an artificial heart valve? Model # ____________
15. Do you have an arterial stent? If yes, approximate date of surgery and the location of the stent/s: __________________________________________________
16. Do you have any tissue expanders? (i.e. breast)
17. Do you have any vascular access port and/or catheter?
Cosmetic
18. Do you have permanent eyeliner?
19. Do you have tattoos? If so, where are they located?
___________________________________________________
20. Are you wearing a wig?
21. Do you have a weave?
22. Do you have ANY body piercings? Location_______________
23. Do you wear removable dentures, false teeth, or a partial plate?
24. Are you wearing an orthodontic retainer or have braces?
Foreign Bodies
25. Have you ever performed metal work such as, grinding, soldering, or welding?
26. Have you ever been injured in your eye by metal objects or metal shavings? If yes, please describe.
______________________________________________________
Foreign Bodies, continued….. Yes No
27. Have you ever been injured by a metallic object or a foreign body such as a bullet, BB, shrapnel, or nails? If yes, please describe. _____________________________________________________
_____________________________________________________
28. Do you have metal fragments in your head, eyes, or skin that are not indicated above? If yes, please describe. _____________________________________________________
Head
29. Do you have any known brain malformations? If yes, please specify type and location. ____________________________
30. Do you have intracranial aneurysm clips?
31. Do you have a spinal or ventricular shunt/s?
32. Do you have a cochlear, otologic, or other ear implant(s)?
33. Do you have a stapedectomy? Do you have a stapes prosthesis?
34. Do you have hearing aid/s? If so, are you wearing them?
Orthopedics
35. Have you had fractured bones treated with rods, metal plates,
pins, screws, nails, or clips? If yes, please specify type and location.__________________________________________
36. Do you have an artificial eye or an eyelid spring?
37. Do you have bone stimulators?
Abdomen/Pelvis
38. Do you have magnetically-activated implant(s) or device(s)?
39. Do you have a vagal nerve stimulator/pain pump?
40. Do you have an insulin pump?
41. Do you have any implanted drug infusion devices?
42. Do you have metal mesh implants?
43. Have you undergone surgery for a hernia?
44. Do you have any implanted radiation seeds or implants?
Abdomen/Pelvis, continued….. Yes No
45. Do you a penile implant? Model # ______________________
46. Do you have an implanted I.U.D. (intra-uterine device)? If so, please include the model number and the year in which it was put in place.____________________________________________
47. Do you have a diaphragm?
48. Do you have a pessary?
Prosthetics
49. Do you have any type of implant held in place by a magnet?
Model #________
50. Do you have an artificial eye or an eyelid spring?
Spine
51. Do you have neurostimulators in place? (TENS unit)
52. Do you have a Harrington rod for scoliosis?
53. Do you have a spinal cord stimulator?
Thank you for your thoughtful attention to these questions. Your safety as a research participant is our primary concern.
By signing below, you acknowledge that you have carefully read and answered each question to the best of your ability.
Research Participant Printed Name: _______________________________________
Research Participant Signature: __________________________________________
Legal Guardian’s Printed Name: _________________________________________
Legal Guardian’s Signature: ____________________________________________
MRI Technologist Signature: ____________________________________________
Signature of Witness: __________________________________________________
Date: ___________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- scenarios for icd 10 cm training
- title of study or project mpog
- cpt codes american society for metabolic bariatric surgery
- ahima press home
- research participant medical history and safety screening
- table 1 coding details for surgery type and comorbidities
- m29 1 part 5 e
- mpog multicenter perioperative outcomes group
- capri gui user manual veterans affairs
Related searches
- medical history form
- medical history form printable
- patient medical history form pdf
- new patient medical history forms
- free patient medical history forms
- medical history of ancient rome
- family care and safety registry
- medical history form pdf
- new patient medical history questionnaire
- medical history template
- personal medical history template excel
- personal medical history form