MRI SCREENING FORM
Name:_________________________________________________
Birth Date:_____/_____/_____
Height:____________________ Weight:___________________ Diabetic or kidney problems? NO YES
Have you ever had surgery? NO YES If yes please list:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had an eye injury involving metal? (Grinding, fabrication, etc.) NO YES
If yes please describe:___________________________________________________________________
Are you pregnant and/or breastfeeding? NO YES
WARNING: Some of the following items may be extremely hazardous to your safety and
interfere
with the
MRI exam. Please circle YES or NO if you have
following.
NO
YES Cardiac
pacemaker
NOtheYES
Shrapnel, buckshot, or bullets
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO YES
NO YES
NO YES
NO YES
Implanted Cardiac Pacemaker / Defibrillator
Aneurysm clip or brain clip
Carotid artery vascular clamp
Neurostimulator
Insulin or Infusion pump
Claustrophobia
Spinal Fusion Stimulator
Cochlear Implant or Ear tubes
Prosthesis (eye, penile, etc.)
Magnetic Implant (dental, etc.)
Heart Valve replacement
Artificial limb or joint
Electrodes (on body, head or brain)
Intravascular stents, filters or coils
Shunt (spinal or intraventricular)
Ports or catheters
Transdermal medicine patches (smoking, pain, etc.)
Hearing Aids
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
IUD, Diaphragm
Pessary or bladder ring
Tattooed eye liner or eyebrows
Body piercings
Metal Fragments
Cosmetic Surgery
Internal pacing wires
Aortic Clips
Venous Umbrella
Metal or wire mesh
Wire sutures or staples
Harrington rods
Screws, pins or nails in the bone
Wig, toupee or hair implants
NO YES Dentures (remove before scan)
NO YES Asthma or breathing disorder
NO YES Seizures or motion disorders
IMPORTANT INSTRUCTIONS: Remove all metallic objects before entering MRI including hearing aids, cell
phone, keys, glasses, hair pins/barrettes, jewelry, watch, safety pins, money clips, credit/bank cards, and coins.
Loose metallic objects are especially prohibited in the MRI environment. Please consult the MRI Technologist if
you have any questions or concerns BEFORE your scan.
Patient/Legal Guardian Signature:___________________________________ Date: _____/_____/_____
MRI Technologist Signature:_______________________________________