MRI Screening Form

WARNING:

You must remove ALL metallic objects before entering the MRI Environment. Certain implants, devices, or objects may be hazardous to you and/or may interfere with the MR procedure (i.e., MRI, MR angiography, functional MRI, MR spectroscopy.) DO NOT ENTER the MR system room or MR environment if you have any questions or concerns regarding an implant, device, or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR System Magnet is ALWAYS on.

MRI Screening Questionnaire

Name

First

Last

DOB

MRN

Referring Physician

Weight

Sex

Briefly describe your symptoms

Any of the following can interfere with MRI. For your safety, please answer completely:

Any history of Cancer or Multiple Sclerosis?

Yes
No

If Yes, Explain

Do you have Sickle Cell Anemia or other blood disorder?

Yes
No

Do you have anything removable in your mouth, i.e. Dentures, retainer?

Yes
No

Do you have permanent Eye Makeup or Tattoos?

Yes
No

If Yes, Explain

Please list or comment on any other metal you have in your body:

List all previous surgeries:

Consent:

I have informed the technologist that I do not have any metallic devices such as a pacemaker, implant, cerebral aneurysm clips in my body or metallic foreign bodies in my eyes. I attest that the answers provided to the questions on this form are correct to the best of my knowledge and understand the information that has been presented to me. The scheduled procedure and contrast administration, if indicated, has been explained. I understand and have had the opportunity to ask questions.

Patient/Guardian Signature

Clear Signature

Date

in any Anemia

Technologist Signature:

Clear Signature

Date

Tech notes: Technologist Use Only

WARNING:

MRI Screening Questionnaire

Any of the following can interfere with MRI. For your safety, please answer completely:

Mission

Hours of Operation

OPTIMUM IMAGING CENTER