Mri Safety Screening Form

UMI MRI Safety Screening Form

Patient Name: ______

Date of Birth: ______

Best Phone Number(s)______

Weight: ______Height: ______Sex: □Female □Male

Females Only: Are you pregnant: □No □Yes Breastfeeding: □No □Yes

Please carefully read and answer the following questions:

1. Have you ever had an MRI? □No □Yes

If yes, give reason and when ______

If yes, did you have any problems with the MRI, or require sedation? □No □Yes

2. Have you EVER had ANY surgery, operations, or heart procedures? □No □Yes

If yes, please indicate approximate year for the most recent surgeries:

Year ______Type of surgery______

Year ______Type of surgery ______

3. Have you ever been injured by a metal object (e.g.: bullet, BB, shrapnel)? □No □Yes

If yes, please describe______

4. Have you ever had an injury to your eyes involving a metal object or fragment? □No □Yes

If yes, please describe______

5. Have you had any imaging (MRI, CT, Ultrasound, X-ray) or treatment on the body part that we are scanning today? □No □Yes

If so, please list:

Approximate Date______Type of imaging/treatment______

6. What problem(s) took you to a doctor that resulted in this MRI scan request?What do you think might have caused the problem and when did it start? ______

______

Please circle the area/s of pain or discomfort on the drawing to the left, indicating symptoms with following letters:

P: Pain

N: Numbness/Tingling

Name: ______

MRI Safety Information:

The MRI scanner is a giant magnet, so any metal can be dangerous. ALL metal and electronic objects should be removed before scanning. This includes: hearing aids, keys, pagers, mobile phones, hairpins, hairclips, jewellery, body piercings, watches, safety pins, credit cards, pens, knives, nail clippers, scissors, tools, clothing with metal fasteners (e.g. zips, press studs), and weapons.
The MRI system is ALWAYS on, so if you have any questions or concerns, please ask the technologist, nurse or radiologist BEFORE you enter the MRI room.

The MRI Scanner is quite loud, so you will be required to wear earplugs or headphones.
Heavy eye/face makeup can interfere with scans in the head and neck region, so should be fully removed for those scans.

Please check Yes or No for each box below, or leave blank if you do not understand.

If you have any questions, please ask for help.

□No □Yes Cardiac (heart) pacemaker or defibrillator.

□No □Yes Ear Implant such as Cochlear or Stapes implant.

□No □Yes Any Stents, Coils or Filters in Blood Vessels, such as a cardiac stent or IVC filter.

□No □Yes Aneurysm clips, or any vascular/aortic clamp, artificial Heart Valves.

□No □Yes Electronic or mechanical implant or device (e.g. implanted medicine infusion

pump, neurostimulator, spinal cord stimulator, penile implant).

□No □Yes CSF Shunt - Spinal or ventricular (programmable or other).

□No □Yes Artificial eye, eyelid spring, limb, or joint. If yes, where:______

□No □Yes Spinal fixation device, fusion, Harrington rods.

□No □Yes Tissue expanders such as one to enlarge the breast.

□No □Yes Metal rod, plates, screws, nails, pins, or wires. If yes, where: ______

□No □Yes Inserted catheter or port (e.g.: port-a-cath, swan ganz, central line).

□No □Yes IUD or Diaphragm.

□No □Yes Dental or Orthodontic appliances: dentures, plates, braces, spacers, bridge.

□No □Yes Hearing aid, Hair pins, wig, or extensions (Remove before entering MRI).

□No □Yes Medication patch (e.g.: nicotine, hormone, contraceptive, pain relief).

□No □Yes Body piercing or Tattoos of any kind. If yes, where:______

I state that the information on this form is correct to the best of my knowledge. I have read and understand the contents of this form and had a chance to ask questions about the MRI scan and this form.

Patient/Guardian Signature: ______Date______

FOR MRI STAFF ONLY: Checked by: ______Date: ______

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