MRI PATIENT SCREENING TOOL
Patient Name
Date
DOB
MR#
Reason for MRI Screening
Have you taken any sedation/alcohol today to relax you for this procedure?
 Yes  No
If yes, what:
If yes, do you have someone to drive you home?
MR Contrast History
 Yes
 No
 Not applicable to this exam
Have you ever had MRI contrast?
Yes  No
Do you have any history of kidney (renal)
insufficiency or failure?
Did you have any kind of reaction?
Are you diabetic?
Yes  No
Do you have any history of
hypertension?
Yes  No
If yes, explain:
FOR FEMALE PATIENTS
Are you taking oral contraceptives or receiving hormonal treatment?
 Yes  No
Are you using or have you ever used implanted birth control, such as IUD or cervical ring?
 Yes  No
Are you currently breastfeeding?
 Yes  No
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
Cardiac Pacemaker
Yes  No
If yes, explain:
Heart surgery/heart valve
Yes  No
If yes, explain:
Implanted cardiac defibrillator (ICD)/cardiac converter
Yes  No
If yes, explain:
Brain aneurysm clips/brain surgery
Yes  No
If yes, explain:
Shunts/stents/filters/intravascular coil
Yes  No
If yes, explain:
Staples
Yes  No
If yes, explain:
Eye surgery/implants/spring/wires/retinal tack
Yes  No
If yes, explain:
Injury to the eye involving metal or metal shavings
Yes  No
If yes, explain:
Orthopedic Pins/screws/rods/joints/prosthesis
Yes  No
If yes, explain:
Neurostimulator/biostimulator
Yes  No
If yes, explain:
Radiation therapy/chemotherapy
Yes  No
If yes, explain:
Previous back surgery (lumbar/thoracic/cervical
Yes  No
If yes, explain:
Ear surgery/cochlear implants/hearing aids/stapes
prosthesis
Yes  No
If yes, explain:
Vascular access port/catheter
Yes  No
If yes, explain:
Electrical/mechanical/magnetic implants
Yes  No
If yes, explain:
 No
Metal mesh implants/wire sutures/wire staples or
clips/internal electrodes
Yes  No
If yes, explain:
Implanted drug infusion pump/insulin pump
Yes  No
If yes, explain:
Tattoos/permanent make-up/body piercing/patches
Yes  No
If yes, explain:
Gunshot wounds/shrapnel/BB
Yes  No
If yes, explain:
Do you have pins in your hair/clothes/hair
extensions/hair pieces/wig
Yes  No
If yes, explain:
Dentures/partials/dental implants
Yes  No
If yes, explain:
History of work involving welding or grinding of sheet
metal
Yes  No
If yes, explain:
History of cancer or tumors:
When:
Where:
ATTENTION! The items listed above can affect the quality of MRI exams and may cause safety hazards.
Presence of these items may influence the way we perform your examination. Please review your responses
before initialing below.
I DO NOT HAVE ANY OF THE ABOVE ITEMS. __________________ (patient to initial here)
Note: Any “Yes” answers are to be reviewed with the MRI Radiologist prior to sca n.
Please remove any metal objects from your person, including, but not limited to:
Body piercings
Identification
badges
Cell phones
Any other
electrically,
magnetically or
mechanically
activated devices
Sharp objects (i.e.
scissors, pocket
knife, nail file, nail
clippers)
Restraining devices or
radiofrequency
ID/tracking bracelets
Pens and pencils
Contraceptive
diaphragms
Keys/key fobs
Steel tools
Credit cards
Jewelry
MP3 players
Tools
Drug delivery
patches
Pagers
Wristwatch
Paper clips
Screened by (2 staff signatures required, please print and sign)
I attest that the above information is correct to the best of my knowledge. I have also informed the technologist that I am not
pregnant at this time and I give consent to have a contrast agent administered to me if needed for proper diagnosis of my
procedure. I acknowledge that I am aware of the possibility of side effects with contrast and I have had the opportunity to ask
questions related to this form, to ask questions regarding the MRI procedure, and I understand the information presented to
me.
Patient/Parent/Legal Guardian:
MRI Technologist:
_____________
Date: ___________
Date: ____________