AVIC MRI SAFETY SCREENING FORM (Visitor)
Visitor Name..................................................................................DOB.............................
Do you have any of the following implants
Pacemaker?
YES
NO
Stents or grafts in your heart or body?
YES
NO
Replacement heart valves?
YES
NO
Aneurysm clips in your brain?
YES
NO
Programmable Hydrocephalus Shunt in your brain?
YES
NO
Cochlear implant?
YES
NO
Neurostimulator?
YES
NO
Have you had any of the following operations
Heart Surgery?
YES
NO
Brain Surgery?
YES
NO
Blood vessel surgery?
YES
NO
Orthopaedic surgery? (e.g. joint replacements, broken bones fixed with metal)
YES
NO
Eye or ear surgery?
YES
NO
Please answer the following questions
Have you had any surgery in the last 8 weeks?
YES
NO
Have you ever had any bullets or shrapnel go into you?
YES
NO
Have you ever had an injury where metal has gone into your eye? (e.g.
grinding, welding, metalwork)
Are you pregnant?
YES
NO
YES
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
Do you have any of the following
Dentures?
Hearing aid?
False limbs, callipers or corsets?
Intra-Uterine Device (IUD or coil)?
Watch?
Credit/Bank cards?
ID badge/bleep?
Jewellery or Body Piercing?
Anything else in your pockets, on your person or in your hair?
You have to be supervised at all times by an MRI Authorised member of personnel whilst on Level 1
of AVIC. Do not walk around the unit on your own and do not grant any other person access to
Level 1 of AVIC. Authorised members of personnel are listed in the MRI local rules.
Visitor Signature.............................................
Radiographer Signature.............................
Date…………..