MRI SCREENING FORM

Please complete at home and bring with you to your appointment.

Name(Required)
Pick one(Required)

Are you claustrophobic?(Required)
If yes, contact your ordering physician prior to scheduled appt
Do you have a PACEMAKER?(Required)
If yes, you CANNOT have an MRI at this facility. Consult with your cardiologist.
Do you have any IMPLANTS?(Required)
If yes, please list name and bring Implant ID Card.

1. Have you had prior surgery?(Required)
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Have you had a prior MRI of the same body part as today?(Required)
If yes, please list when and where it was done:
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Have you had an injury to the eye involving a metallic object or fragment?(Required)
Metallic slivers, shavings, foreign body, etc.
NOTE: *Orbit X-rays may be needed prior to MRI to rule out any possible metal left behind for your safety. If these X-rays have been done in the past, please bring the radiology report.
Have you ever been injured by a metallic object or foreign body?(Required)
BB, bullet, shrapnel, etc.
Are you currently taking any medications?(Required)
Are you allergic to any medication?(Required)
Do you have a history of cancer?(Required)
Do you have a history of asthma, allergic reaction, respiratory disease, or reaction to contrast used for an MRI, CT, or x-ray examination?(Required)
Do you have anemia or any disease(s) that affects your blood, a history of renal (kidney) or liver disease, renal or liver transplant, high blood pressure (hypertension), diabetes, or seizures?(Required)
Are you pregnant or think you may be?
For female patients only
Are you currently breastfeeding?
For female patients only

Do you have any of the following? Please circle yes or no to each question:

Aneurysm clip(s)?(Required)
Cardiac pacemaker?(Required)
Implanted cardioverter defibrillator (ICD)?(Required)
Electronic implant or magnetically activated implant or device?(Required)
Neurostimulation system or Spinal cord stimulator?(Required)
***You must bring ID card AND controller***
Internal electrodes or wires?(Required)
Bone growth/bone fusion stimulator?(Required)
Cochlear, otologic, or another ear implant?(Required)
Insulin or other infusion pump?(Required)
Implanted drug infusion device?(Required)
Any type of prosthesis? (Eye, penile, etc.)(Required)
Heart valve prosthesis?(Required)
Artificial or prosthetic limb?(Required)
Eyelid spring or wire ?(Required)
Metallic stent, filter, or coil?(Required)
Shunt? (Spinal or intraventricular)(Required)
Vascular access port and/or catheter?(Required)
Radiation seeds or implants?(Required)
Swan-Ganz or thermodilution catheter?(Required)
Medication patch or blood glucose monitor?(Required)
(*must be removed*)
Any metallic fragment or foreign body?(Required)
Wire mesh implant?(Required)
Tissue expander (e.g., breast)(Required)
*Most are unsafe; bring ID Card*
Surgical staples, clips, or metallic sutures?(Required)
Joint replacement? (Hip, knee, etc.)(Required)
Bone or joint pins, screws, nails, wires, plates, etc.?(Required)
IUD, diaphragm, or pessary?(Required)
Removable Dentures or partial plates?(Required)
Tattoo or permanent makeup?(Required)
Body piercing, jewelry?(Required)
(*must be removed*)
Hearing aid?(Required)
(***Remove before entering MRI room***)
Breathing problem or motion disorder?(Required)
Implants(Required)
NOTE: Before entering the MRI Room, you must remove all metallic objects and clothing with metallic threads, snaps, etc. Please consult the MRI Technologist if you have any questions or concerns BEFORE you enter the MRI system room.
Signature of Patient
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