MRI SCREENING OF NON-PATIENTS

DEPARTMENT OF DIAGNOSTIC IMAGING

WARNING: 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. Do not enter the MR environment or MR system room if you have any questions or concerns regarding an implant, device or object.

Note: If you are a patient preparing to undergo an MR examination, you are required to fill out a different form.

Name
Last Name / First Name

Date

/

Telephone

/ ( ) / -
Day / Month / Year
1. / Have you had prior surgery or an operation (e.g. heart surgery, brain surgery, orthopedic surgery, arthroscopy, endoscopy, etc.) of any kind? If yes, please indicate date and type of surgery: / o / No / o / Yes
Date: / Type of Surgery:
Implants used (if applicable):
2. / Have you had an injury to the eye involving a metallic object (e.g. metallic slivers, foreign body.)? / o / No / o / Yes
If yes, please describe:
Orbit exam results (if applicable):
3. / Have you ever been injured by a metallic object or foreign body (e.g. BB, bullet, shrapnel, etc.)? / o / No / o / Yes
If yes, please describe:
4. / Are you pregnant or suspect that you are pregnant? / o / No / o / Yes
Please indicate if you have any of the following:
o / No / o / Yes / Aneurysm clip(s)
o / No / o / Yes / Cardiac pacemaker
o / No / o / Yes / Implanted cardioverter defibrillator (ICD)
o / No / o / Yes / Electronic implant or device
o / No / o / Yes / Magnetically-activated implant or device
o / No / o / Yes / Neurostimulation system
o / No / o / Yes / Spinal cord stimulator
o / No / o / Yes / Cochlear implant or implanted hearing aid
o / No / o / Yes / Insulin or infusion pump
o / No / o / Yes / Implanted drug infusion device
o / No / o / Yes / Any type of prosthesis or implant
o / No / o / Yes / Artificial or prosthetic limb
o / No / o / Yes / Any metallic fragment or foreign body
o / No / o / Yes / Any external / internal metallic object (drug patch, etc.)
o / No / o / Yes / Hearing aid (remove before entering the MR system room)
o / No / o / Yes / Intra-uterine device (IUD)
o / No / o / Yes / Other implant

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 / Day / Month / Year
Information Reviewed By:
Print Name / Signature

Form# 38868 Last Revision Date: 26 July, 2005