MRI SCREENING QUESTIONNAIRE
If you have medication to take prior to the MRI, please notify office staff now. Thank you.
The following items can interfere with the MRI imaging and some may be hazardous to your safety. Please complete thoroughly.
NAME _____________________________________________________ Height __________Weight ____________
PLEASE PRINT
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Do you have an implant that the surgeon provided you a card for? If yes, please provide us with a copy.
Heart Surgery (including PACEMAKER, coronary artery bypass, stent or heart valve)? (please circle)
Neurostimulator (TENS Unit) or Electrode Implant?
Have you ever had brain surgery (including shunt placement) or brain aneurysm surgery?
Have you ever had ear surgery? If YES, what type __________________________________
Do you have any removable dental work?
Do you have anything foreign/metal in your body? If YES, what/where ___________________________
Do you have an INSULIN PUMP, HEARING AID, or IUD? If YES, please circle
Have you ever had an incident of metal fragments/shrapnel in your eyes? head? Or skin? (please circle)
Do you have tattoo eyeliner?
Do you have Seizures or Epilepsy?
Are you pregnant, suspect pregnancy or breast feeding?
Have you had ANY SURGICAL PROCEDURES? If YES, list below with date.
Do you have any ALLERGIES or REACTIONS to drugs or substances? If YES, specify below.
Do you have a history of kidney function problems or are you diabetic (controlled by medications)?
All medical procedures carry an element of risk and this procedure is no exception. The use of contrast media may provide more
information to evaluate your problems and improve the quality of your exam. The contrast media “Gadolinium” is a water base
substance which is NOT iodine. The most common adverse experience noted by patients receiving contrast is headache and
nausea. Additional adverse events occur in less than 1% of patients. If you have renal insufficiency or have been diagnosed with
renal disease, please notify your technologist immediately. Your physician has considered the aforementioned risks before
recommending this exam and he/she believes the diagnostic benefits outweigh the minimal risks involved.
I have read the above and give my consent to the performance of the MRI scan(s) ordered, including administration of contrast
material, if indicated.
______________________________________________________________________________________________
Signature of patient or guardian
Date/Time
Person completing form: ____________________________________________________________________________
_______________________________________________________________________________________________
Witness
Date/Time
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(Office use only)
Contrast: __________
Lot# __________
Expiration Date: __________
Amount Injected: __________
Technologist: __________
Radiologist: __________ GFR (if applicable): __________