308871579
CUBRIC, CARDIFF UNIVERSITY - MAGNETIC RESONANCE IMAGING UNIT
INITIAL SCREENING FORM
NAME OF PARTICIPANT …………………………………………………
Date of birth………………………
Sex: M / F
CUBRIC UNIQUE IDENTIFIER: ………………………………………
Please read the following questions CAREFULLY and provide answers. For a very small number of
individuals, being scanned can endanger comfort, health or even life. The purpose of these questions
is to make sure that you are not such a person. You have the right to withdraw from the screening and
subsequent scanning if you find the questions unacceptably intrusive. 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 technical terms are given
overleaf.
Please answer all questions
Circle answer
1. Have you been fitted with a pacemaker, 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 had a heart valve replacement
YES/NO
4. Have you ever had any metal fragments in your eyes?
YES/NO
5. Have you had a cochlear implant fitted
YES/NO
6. Do you wear a hearing aid?
YES/NO
7. Do you have any other mechanical/electrical or magnetically operated devices in or
on your body?
YES/NO
8. Have you ever had any metal fragments, e.g. shrapnel in any other part of your body?
YES/NO
9. Have you any surgically implanted metal in any part of your body (e.g. joint
replacement or bone reconstruction, pins, rods, screws, nails, clips, plates, wires).
YES/NO
10. Have you ever had any surgery that might have involved metal implants of which
you are not aware?
YES/NO
11.Do you have a catheter fitted?
12.Do you have any intra-venous devices fitted (including stents and filters)
YES/NO
YES/NO
13. Do you have any Tattoos?
YES/NO
14. Is there any possibility that you might be pregnant?
YES/NO
15. Have you been sterilised using clips?
YES/NO
16. Do you have a contraceptive coil (IUD) installed?
YES/NO
17. Do you have any dental work (including dentures, crowns, bridgework, braces) in
your mouth, other than simple fillings?
YES/NO
18. Have you ever suffered from any of: epilepsy, diabetes or thermoregulatory
problems?
YES/NO
19. Have you ever suffered from any heart disease?
YES/NO
20. Do you have any permanent eye makeup?
YES/NO
PLEASE TURN TO NEXT PAGE
308871579
I have read and understood the questions above and have answered them correctly.
SIGNED…………………………………
DATE…………………………
In the presence of ………………………………….. (Name) ………………………………….. (Signature)
Please enter here the name and address of your doctor (general practitioner)
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
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Volunteer scan log
Date
Study Code
Investigator confirmed review of
initial screening form
308871579
DEFINITIONS OF TECHNICAL TERMS
PACEMAKER: An electronic device that is surgically placed in the patient's body and connected to the heart to
regulate the heartbeat. The safe operation of a pacemaker can be temporarily or permanently disrupted
if a patient 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 promote unblocked and enhanced 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.