MRI-SAFETY QUESTIONNAIRE
Please bring this completed form with you to your appointment
It is very important that all MRI staff have been made aware of any metallic objects
that have ever been in your body. Certain implants, devices, or objects may be
hazardous to you and/or may interfere with the MR procedure.
IF YOU ANSWER YES TO QUESTIONS 2-20 INCLUSIVE PLEASE CONTACT
THE MRI UNIT PRIOR TO YOUR APPOINTMENT ON: TELEPHONE (01423)
554474 (please leave your name and contact number on the answer phone).
Please Tick
Yes
No
1. Have you had an MRI scan before?
If so please state which hospital and date of scan.…………………
………………………………………………………………………………………
2. Have you ever had a cardiac pacemaker?
If yes please state which hospital………………………………………
3. Have you had any operations to your heart?
If so please give details……………………………………………......
…………………………………………………………………………………….
4. Have you ever had an angiogram? (This is a test to look at your blood vessels)
5. Have you, at any time, had metal fragments in your eye?
6. Have you had any operations to your head, brain, eyes or spine?
If so please give details ……………………………………………….
……………………………………………………………………………….……
7. Do you have any implanted electrical devices?
8. Have you had any operations/procedures in the last 2 months?
If so please give details ……………………………………………….
…………………………………………………………………………………
9. Have you had any operations/procedures involving the use of metal clips, pins,
plates or implants?
If so please give detail details …………………………………………..
…………………………………………………………………….…………………
10. Have you, at any time, had any metal fragments in any other part of your body?
The following questions apply to female patients only
11. Are you, or is there any possibility that you may be pregnant?
12. Are you breastfeeding?
13. Do you have a contraceptive coil fitted?
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Please Tick
Yes
No
14. Have you had an injection of MRI contrast (dye) in the last 7 days?
15. Do you have any kidney or liver problems?
If so please give detail details ………………………………………………..
…………………………………………………………………………………
16. Do you suffer from severe angina?
ie, do you use GTN daily or when at rest
17. Have you had a heart attack in the last 6 weeks?
18. Do you have any drug allergies or are allergic to anything else, ie latex?
If so please give detail details ………………………………………………..
…………………………………………………………………………………
19. Are you wearing a skin patch i.e. hormone/pain relief/nicotine?
20. Do you have mobility problems and require assistance in moving?
For hospital use only:
Insert Patient Sticker here or complete the below
details.
Hospital ID:
Patient Name:
Patient’s Weight (approximately)
…………………………………………..
Patient Date of Birth:
I confirm that I have been asked the questions overleaf and the information is correct to the best of my knowledge. I
consent to the MRI scan.
Signature of patient ……………………………………………………………………………………
Signature of member of staff ………………………………………………Date…………………….
This patient has attended the Radiology Department for an MRI examination involving an injection of intravenous contrast
medium.
The IV cannula was inserted/checked to be patent prior & post infusion (delete) by ……………………….. Radiographer.
The IV cannula was flushed prior infusion with 10mls Sodium Chloride 0.9% Lot No……….. Exp date…………
The injector pump was loaded by ………………………….. Radiographer with
……….. mls of Multihance/Prohance Lot No………………….……… Exp date………………
……….. mls of Sodium Chloride 0.9% Lot No………………………... Exp date……………… post infusion
was administered at ………..am/pm on ……./……./…….. by …………………..………….. Radiographer
-XXXThis patient has attended the Radiology Department for an examination involving an intravenous injection of Buscopan.
The IV cannula was inserted / checked to be patent prior / post infusion [delete] by…………………..…… Radiographer
The injection was drawn up by ………………………………………………………….
The IV cannula was flushed prior and post infusion with 10mls Sodium Chloride 0.9% Lot No………… , Exp Date..….
………… mls of Buscopan, Lot No.................., Expiry Date ……………...was administered at ……… am/pm on ….../….../…...
by……………………….…………….…Radiographer
A possible side effect of Buscopan is visual accommodation disturbances.
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