UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS
DEPARTMENT OF RADIATION ONCOLOGY
MRI CONSENT & SAFETY QUESTIONNAIRE
Patient’s Height: ____ ft____in. Weight:____kg/lb
Place Sticker Here
Travel (Circle): Wheelchair / Stretcher / SWAT
DO YOU HAVE A HISTORY OF THE FOLLOWING: (Please circle Yes, No, or N/A)
1. Have you experienced any problems related to a previous MR Procedure?
If Yes, describe:_____________________________________________
2. Have you ever had an allergic reaction to MRI contrast (Gadolinium)?
3. Have you ever received steroid prep for gadolinium enhanced MRI at UMH or another
institution?
4. Have you ever had a life threatening allergic reaction to anything?
5. Do you have sickle cell anemia?
6. Are you pregnant or nursing (lactating)?
7. Have you ever had kidney failure; kidney or bladder surgery; kidney transplant or have
you been told you have poor kidney function?
If Yes: Creatinine____ BUN____ eGFR____
9. Do you have breathing difficulties or are you on Oxygen or a Ventilator?
10. Have you had a capsule endoscopy in the last 30 days?
11. Do you have Calypso beacons implanted?
12. Have you had any of the following surgeries/implants/devices,
If Yes, indicate Type & Date:______________________________
Cardiac pacemaker, pacemaker or pacemaker wires
Any type of heart surgery, artificial heart valve
Brain aneurysm surgery or aneurysm clips
Cochlear, otologic, middle ear or other ear implants
Cataract surgery/ eye lens implant
Mechanical/electrical/stimulators/pumps or devices
Neurostimulator/deep brain stimulator/vagal nerve stimulator
Artificial limb or prosthesis
Metal tracheostomy
13. Any previous surgery not listed above?
If Yes, indicate Type & Date :_______________________
14. Have you ever sought medical attention for a piece of metal in your eye?
15. Do you have difficulty standing without assistance?
16. Are you claustrophobic? If Yes, do you need a sedative?
17. Is the patient physically/mentally impaired or unresponsive?
18. Do you have uncontrollable shaking or breathing problems?
19. Do you have trouble lying on your back for more than one hour?
20. If you have any of the following items inside your body, please circle the item:
Bullets/BB’s/pellets/shrapnel
Tattoo/permanent make-up
Metal fragments
Surgical clips/staples
Wires/plates/screws/pins
Shunts/stents/coils/filters
Programmable Shunts
EKG patches
Transdermal med. patches
Hearing aids
Dental implants
IUD/Prosthesis (penile, etc)
Breast implants
Blood clot filter
Insulin/infusion/IV pump
X
Signature of person completing the questionnaire
Date
Signature of MR Staff reviewing form
Date
Yes
No
N/A
Yes
Yes
No
No
N/A
N/A
Yes
Yes
Yes
Yes
No
No
No
No
N/A
N/A
N/A
N/A
Yes
Yes
Yes
No
No
No
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
N/A
N/A
N/A
N/A
N/A
N/A
Bone/Neuro Stimulator
Vascular access port/catheter
Foley with temp. probe
Swan Ganz catheter
Dentures/retainers/braces
Form Completed by (Please Circle): Patient / Family: (Relationship) _________________ / UMHS Staff / Other: _________________
IMPORTANT: THE MRI SYSTEM IS ALWAYS ON! PLEASE REMOVE ALL BODY PIERCING /JEWLERY /
HAIRPINS AND OTHER METAL OBJECTS BEFORE ENTERING PROCEDURE ROOM. YOU WILL BE
REQUIRED TO CHANGE INTO A GOWN AND WEAR EARPLUGS FOR SAFETY REASONS.
Aug 2011 JF
What to do if “Yes” was answered:
#2, 3 or 4
The pt. will need a steroid prep. This will require an Rx from the Dr. and the pt.
must be scheduled according to the allotted prep.
#14
Pt. must be sent for Orbit X-rays and have images approved by Radiologist.
This will require an Rx from the Dr. The pt. should arrive 30min prior to
scheduled MR Simulation
Any other “Yes” answers should be brought to the attention of the MRI Level II Safety Officer
Aug 2011 JF