MAGNETIC RESONANCE IMAGING INITIAL SCREENING FORM
NAME OF PARTICIPANT..............................................................................
Date of birth………………………
Sex: M / F
Weight in kg……… or Stones/lbs Height in cm or m………………
Please read the questions on this screening form CAREFULLY. Your safety in the magnetic environment
is our primary concern. THIS IS VERY IMPORTANT. For a very small number of individuals, being
scanned can be uncomfortable, or endanger health or even life. The purpose of these questions is to
make sure that you are not such a person. 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 the more technical terms are given overleaf.
I wish to be screened by the same gender
YES/NO*
Please answer all questions
Bold
answer
1. Have you been fitted with a pacemaker, artificial heart valve, cochlear implant 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 ever had any metal fragments in your eyes?
YES/NO
4. Have you been exposed in your life to metal debris as a result of welding, grinding, filing, sawing or drilling of
metal either occupationally or recreationally?
YES/NO
5. Do you wear a hearing aid?
YES/NO
6. Have you ever had any metal fragments, e.g. shrapnel in any other part of your body?
YES/NO
7. Have you any surgically implanted metal in any part of your body (e.g. joint replacement or bone
reconstruction)?
YES/NO
8. Have you ever had any surgery that might have involved metal implants of which you are not aware?
YES/NO
9. Is there any possibility that you might be pregnant?
YES/NO
10. Do you have a contraceptive coil (IUD) installed?
YES/NO
11. Have you been sterilised using clips?
YES/NO
12. Do you have any dental work (including dentures, crowns, bridgework, braces) in your mouth, other than
simple fillings?
YES/NO
13. Have you ever suffered from any of: epilepsy, diabetes or thermoregulatory problems?
YES/NO
14. Have you ever suffered from any heart disease?
YES/NO
15. Do you have any tattoos? Do you have any permanent eye makeup?
YES/NO
16. Are you wearing any skin patches? (eg. Nicotine )
YES/NO
I have read and understood the questions above and have answered them correctly.
SIGNED……………………………….......................................
DATE…………………………
In the presence of ………………………………….. (Name) …………………………………..
(Signature)
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STON UNIVERSITY - MAGNETIC
Appendix RESONANCE IMAGING UN
Definition of Technical Terms
PACEMAKER: An electronic device that is surgically placed in the patient's body and
connected to the heart to control the heartbeat. The safe operation of a pacemaker can be
temporarily or permanently disrupted if a person with a pacemaker 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 improve 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.
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