The following are sample questions that you will be asked prior to your mri exam. These questions are asked for your safety. By reviewing these questions in advance, you will speed up the registration process, and therefore shorten your exam time. A downloadable Adobe Acrobat file that you can fill out and present to the staff is available as well. Filling this form out in advance will reduce your time for registration time significantly.
P R E - M R I S C R E E N I N G F O R M
Height
click to download adobe reader
Weight
Birth Date
Social Security No.______/_____/________
Address City
State Zip Code Phone (H)(_____) (W)(_____)
Physicians name & address
_____________________________________________________________
1. Have you ever had surgery or any similar invasive procedure? o No o Yes
If yes, please list:
Type: Date: _____/_____/_____
Type: Date: _____/_____/_____
2. Have you had any previous studies? o No o Yes
If yes, please list:.
Body part Date Facility Location
MRI _____/_____/_____
CT/CAT Scan ____/_____/_____
X-Ray _____/_____/_____
Ultrasound _____/_____/_____
Nuclear Medicine _____/_____/_____
3. Have you ever worked with metal (grinding, fabricating, etc.) or ever had an injury to the eye involving a metallic object (e.g., metallic slivers, shavings, foreign body)?
If yes, please describe:
4. Are you pregnant or experiencing a late menstrual period?
5. Are you breast feeding?
6. Date of last menstrual period: _____/_____/____
7. Are you taking any type of fertility medication or having fertility treatments?
8. Are you taking oral contraceptives or receiving hormone treatment?
9. Are you currently taking or have you recently taken any medication?
If yes, please list:
10. Do you have anemia or any blood diseases , a history of renal disease or seizures?
If yes, please describe:
11. Do you have drug allergies?
If yes, please list: _
12. Have you ever had asthma, allergic reaction, respiratory disease, or other reaction to a contrast medium
or dye used for an MRI or CT examination?
If yes, please describe:
Some of the following items may be hazardous to your safety and some can interfere with the MRI examination.
Please check the correct answer for each of the following. Do you have any of the following:
o Yes o No Cardiac pacemaker
o Yes o No Implanted cardiac defibrillator
o Yes o No Aneurysm clip(s)
o Yes o No Carotid artery vascular clamp
o Yes o No Neurostimulator
o Yes o No Insulin or infusion pump
o Yes o No Implanted drug infusion device
o Yes o No Bone growth/fusion stimulator
o Yes o No Cochlear, otologic, or ear implant
o Yes o No Any type of prosthesis (eye, penile, etc.)
o Yes o No Heart valve prosthesis
o Yes o No Artificial limb or joint
o Yes o No Electrodes (on body, head, or brain)
o Yes o No Intravascular stents, filters, or coils
o Yes o No Shunt (spinal or intraventricular)
o Yes o No Vascular access port and/or catheter
o Yes o No Swan-Ganz catheter
o Yes o No Any implant held in place by a magnet
o Yes o No Transdermal delivery system (Nitro)
o Yes o No IUD or diaphragm
o Yes o No Tattooed makeup (eyeliner, lips, etc.)
o Yes o No Body piercing(s)
o Yes o No Any metal fragments
o Yes o No Internal pacing wires
o Yes o No Aortic clip
o Yes o No Metal or wire mesh implants
o Yes o No Wire sutures or surgical staples
o Yes o No Harrington rods (spine)
o Yes o No Metal rods in bones
o Yes o No Joint replacement ______________
o Yes o No Bone/joint pin, screw, nail, wire, plate
o Yes o No Hearing aid (Remove before MRI)
o Yes o No Dentures (Remove before MRI)
o Yes o No Breathing disorder
o Yes o No Motion disorder
o Yes o No Claustrophobia
o Yes o No Anxiety
Other, please explain:___________________________
Please mark on the figure below,
the location of any implant or metal
inside of or on your body.
Before your MRI, please remove all metallic objects including keys, hair pins, barrettes, jewelry, watch, safety pins, paperclips, money clip, credit cards, coins, pens, belt, metal buttons, pocket knife, & clothing with metal in the material.