CUBRIC - MRI Initial Screening Form_10.doc

CUBRIC, CARDIFF UNIVERSITY - MAGNETIC RESONANCE IMAGING UNIT

INITIAL SCREENING FORM

NAME OF PARTICIPANT ………………………………………………… Sex: M / F

Date of birth……………………… CUBRIC UNIQUE IDENTIFIER: ………………………………………

Please read the following questions CAREFULLY and provide answers. For a very small number of individuals, being scanned can endanger comfort, health or even life. The purpose of these questions is to make sure that you are not such a person. You have the right to withdraw from the screening and subsequent scanning if you find the questions unacceptably intrusive. The information you provide will be treated as strictly confidential and will be held in secure conditions.

If you are unsure of the answer to any of the questions, please ASK the person who gave you this form or the person who will be performing the scan. Definitions of some of technical terms are given overleaf.

Please answer all questions / Circle answer
1. Have you been fitted with a pacemaker, or any other implanted device? / YES/NO
2. Have you any surgical clips, aneurysm clips, shunts or stents in your body? / YES/NO
3. Have you had a heart valve replacement / YES/NO
4. Have you ever had any metal fragments in your eyes? / YES/NO
5. Have you had a cochlear implant fitted / YES/NO
6. Do you wear a hearing aid? / YES/NO
7. Do you have any other mechanical/electrical or magnetically operated devices in or on your body? / YES/NO
8. Have you ever had any metal fragments, e.g. shrapnel in any other part of your body? / YES/NO
9. Have you any surgically implanted metal in any part of your body (e.g. joint replacement or bone reconstruction, pins, rods, screws, nails, clips, plates, wires). / YES/NO
10. Have you ever had any surgery that might have involved metal implants of which you are not aware? / YES/NO
11.Do you have a catheter fitted? / YES/NO
12.Do you have any intra-venous devices fitted (including stents and filters) / YES/NO
13. Do you have any Tattoos? / YES/NO
14. Is there any possibility that you might be pregnant? / YES/NO
15. Have you been sterilised using clips? / YES/NO
16. Do you have a contraceptive coil (IUD) installed? / YES/NO
17. Do you have any dental work (including dentures, crowns, bridgework, braces) in your mouth, other than simple fillings? / YES/NO
18. Have you ever suffered from any of: epilepsy, diabetes or thermoregulatory problems? / YES/NO
19. Have you ever suffered from any heart disease? / YES/NO
20. Do you have any permanent eye makeup? / YES/NO

PLEASE TURN TO NEXT PAGE

I have read and understood the questions above and have answered them correctly.

SIGNED………………………………… DATE…………………………

In the presence of ………………………………….. (Name) ………………………………….. (Signature)

Please enter here the name and address of your doctor (general practitioner)

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Volunteer scan log

Date / Study Code / Investigator confirmed review of initial screening form

DEFINITIONS OF TECHNICAL TERMS

PACEMAKER: An electronic device that is surgically placed in the patient's body and connected to the heart to regulate the heartbeat. The safe operation of a pacemaker can be temporarily or permanently disrupted if a patient goes near an MRI scanner.

COCHLEAR IMPLANT: An electronic medical device that bypasses damaged structures in the inner ear and directly stimulates the auditory nerve, allowing some deaf individuals to learn to hear and interpret sounds and speech.

ANEURYSM CLIP: A surgically implanted metal clip used to cut off blood flow through the neck of an aneurysm. An aneurysm is a deformity of a blood vessel in the body, which can swell and burst causing a haemorrhage.

SHUNT: A surgically implanted connector, which allows passage of fluid between two parts of the body. A common use of a shunt is to allow fluid to drain away from the brain, thus reducing pressure in the brain. May also describe a tube which allows blood to be moved from one part of the body to another.

STENT: A surgical implanted device that is inserted into a blood vessel to provide support, keep the vessel open and promote unblocked and enhanced blood flow. Sometimes used in other fluid carrying vessels in the body such as bile ducts etc.

THERMOREGULATORY PROBLEMS: Thermoregulation is the body’s in-built ability to keep all parts of your body at their correct temperature. Some illnesses prevent the person from properly controlling the temperature of their body. If you think you may have such an illness, please answer “YES” and discuss it with the person who gave you the form, or the person who is in charge of the scan.