UCL INSTITUTE OF NEUROLOGY
WELLCOME TRUST CENTRE FOR NEUROIMAGING
LEOPOLD MÜLLER FUNCTIONAL IMAGING LABORATORY
FUNCTIONAL IMAGING LABORATORY (FIL)
NEUROIMAGING: PARTICIPANT SAFETY QUESTIONNAIRE
TO BE COMPLETED IN ALL MODALITIES OF NEUROIMAGING
The handling, processing, storage and destruction of data will be conducted in accordance with the Data Protection Act (1998).
I. The absolute contra-indications for MRI scanning are listed below. If you answer yes to any of the
following we will not be able to scan you:
Yes
No
Do you have a cardiac pacemaker or artificial heart valves?
Do you have cerebral aneurysm clips?
Have you had any neurosurgery including the insertion of clips or
plates?
Have you ever had a job in the metal-working industry or have you ever
been exposed to metal dust or splinters?
Have you ever had an injury to your eyes involving metal?
Have you undergone permanent eyelining as a cosmetic procedure?
Have you any cochlear implants (ear implants)?
II. Before entering the MRI scan room please inform us if any of the following apply:
Yes
No
Unsure
Yes
No
Unsure
Have you had any surgery?
Are any artificial devices implanted into your body (e.g. joint
replacements, coils, implants or clips)?
Do you wear a false limb, caliper, brace, or have any artificial
devices attached to your body (e. g clips or rings)?
Do you wear a hearing aid or have dentures, bridges, braces,
dental or breast implants?
Do you have any shrapnel from a war injury or explosion?
Do you have an infusion pump or hickman line?
Are you diabetic, epileptic or ever had a seizure?
Are you wearing Nicotine patches?
Do you have tattoos?
Have you removed all loose metal objects, wallets, watches, bra
and jewellery from your person?
Full Name
(print)……………………………………................................................
Signature…………………………………..............................................
Date:……………………………………………………
For female volunteers only:
Could you be pregnant?
Are you wearing a diaphragm / Interuterine Device (Coil) or any
other contraceptive device?
Are you wearing any hormone replacement contraceptive
patches?
Signature:……………………………………………
Neuroimaging Safety questionnaire: All modalities Page 1 of 1
Date:…………………………
Version: 1.0 Date: 12-03-08
Supersedes: “Last revised 12/2004”
Neuroimaging Safety questionnaire: All modalities Page 2 of 1
Version: 1.0 Date: 12-03-08
Supersedes: “Last revised 12/2004”