MRI Screening Questionnaire



MRI Screening Questionnaire

Name:_______________________________________________ Date:_________

Sex: M F SSN:________________________

| |NO |YES |

|1. Have you ever had a surgical procedure of any kind? If yes, please list all prior surgeries and approximate| | |

|dates. | | |

|2. Have you ever been injured by any metallic foreign body, e.g. bullet, shrapnel, metal slivers in eye, etc.? | | |

|Please describe: | | |

|3. Do you have anemia or a disease that affects your blood? Describe: | | |

|4. Do you have a history of renal disease, seizure, asthma, or allergic respiratory disease? | | |

|5. Are you certain that you are not pregnant? | | |

|6. Are you breast-feeding? | | |

|7. Are you taking oral contraceptives or receiving hormone treatment? | | |

|8. Last menstrual period (if applicable): | | |

|9. Do you have trouble riding in an elevator? | | |

Pertinent Previous Studies

Body Part Date Procedure

______________________________________________ X-ray

______________________________________________ Computed Tomography (CT)

______________________________________________ Ultrasound

______________________________________________ Nuclear Medicine

______________________________________________ MRI

The following items may be hazardous or may interfere with the MRI examination by producing an artifact. Please indicate if you have any of the following. Note that questionnaire continues on reverse side of this page.

| |NO |YES |

|1. Metal hernia truss | | |

|2. Tattoo(s) | | |

|3. Any implanted metal or orthopedic item (e.g., plates, pins, rods, screws, nails, clips, wires, etc.) | | |

|anywhere in body (e.g., knee, hip, back, other joints, etc.) | | |

|4. Chest, brain, heart, or abdomen aneurysm clips | | |

|5. Metal cranial plate | | |

|6. Eye or ear implants or prosthesis | | |

|7. Heart valve prosthesis | | |

|8. Implanted cardiac defibrillator | | |

|9. Any type of biostimulator | | |

|10. Any type of internal electrode | | |

|11. Pacing wires | | |

|12. Implanted insulin pump | | |

|13. Swan-Ganz catheter | | |

|14. Halo vest or metallic cervical fixation device | | |

|15. Any type of electronic, mechanical, or magnetic implant | | |

|16. Any type of intravascular coil, filter or stent (Gianturco coil, Gunther IVC filter, Plamaz stent, etc.) | | |

|17. Implanted drug infusion device | | |

|18. Penile prosthesis | | |

|19. Any type of implant held in place by a magnet | | |

|20. Any type of surgical clip or staple(s) | | |

|21. Vascular access port | | |

|22. Intraventricular shunt | | |

|23. Artificial limb or joints | | |

|24. IUD | | |

|25. Diaphragm | | |

|26. Pessary | | |

|27. Body piercing | | |

If any “yes” responses have been indicated above, then please bring the potentially problematic items to the attention of the examiner. The above information will be reviewed prior to your scan. You will need to remove eye make-up, dentures, hairpins or bands, earrings, necklaces, watches, hearing aids and glasses.

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 I have had the opportunity to ask questions regarding the information in this form, and agree to participate in the study.

Patient’s signature:____________________________________________ Date:_______

Examiner’s signature:__________________________________________ Date:_______

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