UMI MRI Safety Screening Form
Patient Name: ________________________________________________
Date of Birth: ________________________________________________
Best Phone Number(s)_________________________________________
□Female □Male
Breastfeeding: □No □Yes
Weight: _____________ Height: ____________ Sex:
Females Only: Are you pregnant: □No □Yes
Please carefully read and answer the following questions:
1. Have you ever had an MRI? □No □Yes
If yes, give reason and when _________________________________________________________
If yes, did you have any problems with the MRI, or require sedation?
□No □Yes
2. Have you EVER had ANY surgery, operations, or heart procedures? □No □Yes
If yes, please indicate approximate year for the most recent surgeries:
Year _________ Type of surgery_____________________________________
Year _________ Type of surgery ____________________________________
Year _________ Type of surgery ____________________________________
3. Have you ever been injured by a metal object (e.g.: bullet, BB, shrapnel)? □No □Yes
If yes, please describe_______________________________________________________________
4. Have you ever had an injury to your eyes involving a metal object or fragment? □No
If yes, please describe_____________________________________________________
□Yes
5. Have you had any imaging (MRI, CT, Ultrasound, X-ray) or treatment on the body part that we are
scanning today? □No □Yes
If so, please list:
Approximate Date_______________ Type of imaging/treatment____________________________
Approximate Date_______________ Type of imaging/treatment____________________________
6. What problem(s) took you to a doctor that resulted
in this MRI scan request? What do you think might
have caused the problem and when did it start?
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Please circle the area/s of pain or discomfort on the
drawing to the left, indicating symptoms with
following letters:
P: Pain
N: Numbness/Tingling
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UMI MRI Safety Screening Form
Name: ______________________________________________________________
MRI Safety Information:
 The MRI scanner is a giant magnet, so any metal can be dangerous. ALL metal
and electronic objects should be removed before scanning. This includes: hearing aids, keys, pagers,
mobile phones, hairpins, hairclips, jewellery, body piercings, watches, safety pins, credit cards,
pens, knives, nail clippers, scissors, tools, clothing with metal fasteners (e.g. zips, press studs), and
weapons.
 The MRI system is ALWAYS on, so if you have any questions or concerns, please ask the
technologist, nurse or radiologist BEFORE you enter the MRI room.
 The MRI Scanner is quite loud, so you will be required to wear earplugs or headphones.
 Heavy eye/face makeup can interfere with scans in the head and neck region, so should be fully
removed for those scans.
Please check Yes or No for each box below, or leave blank if you do not understand.
If you have any questions, please ask for help.
□No
□No
□No
□No
□No
□Yes
□Yes
□Yes
□Yes
□Yes
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
Cardiac (heart) pacemaker or defibrillator.
Ear Implant such as Cochlear or Stapes implant.
Any Stents, Coils or Filters in Blood Vessels, such as a cardiac stent or IVC filter.
Aneurysm clips, or any vascular/aortic clamp, artificial Heart Valves.
Electronic or mechanical implant or device (e.g. implanted medicine infusion
pump, neurostimulator, spinal cord stimulator, penile implant).
CSF Shunt - Spinal or ventricular (programmable or other).
Artificial eye, eyelid spring, limb, or joint. If yes, where:______________________
Spinal fixation device, fusion, Harrington rods.
Tissue expanders such as one to enlarge the breast.
Metal rod, plates, screws, nails, pins, or wires. If yes, where: ___________________
Inserted catheter or port (e.g.: port-a-cath, swan ganz, central line).
IUD or Diaphragm.
Dental or Orthodontic appliances: dentures, plates, braces, spacers, bridge.
Hearing aid, Hair pins, wig, or extensions (Remove before entering MRI).
Medication patch (e.g.: nicotine, hormone, contraceptive, pain relief).
Body piercing or Tattoos of any kind. If yes, where: _________________________
I state that the information on this form is correct to the best of my knowledge. I have read and
understand the contents of this form and had a chance to ask questions about the MRI scan and this
form.
Patient/Guardian Signature: __________________________________ Date___________________
FOR MRI STAFF ONLY: Checked by: ________________________ Date: __________________
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