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MRI Safety Screening Form

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MRI Safety Screening Form Powered By Docstoc
					                                               MRI Safety Screening Form
                         PLEASE CIRCLE “YES” OR “NO” FOR EACH QUESTION BELOW:

1. Have you ever had an MRI examination before?....................................................................... Yes No
   Did you have a problem being able to complete an MRI scan?................................................. Yes No
   If yes, please describe _________________________________________
2. Have you ever had a surgical operation or procedure of any kind? .......................................... Yes No
   If yes, please list all prior surgeries and approximate dates:
___________________________________________________________________________________
___________________________________________________________________________________
3. Have you ever been injured by a metal object or foreign body (e.g., bullet, BB, shrapnel)?...... Yes No
   If yes, please describe
___________________________________________________________________________________
___________________________________________________________________________________
4. Have you ever had an injury from a metal object in your eye (metal sliver, metal shavings,
   other metal object)? ................................................................................................................... Yes No
        If yes, did you seek medical attention? ................................................................................. Yes No
5. Do you have a history of kidney disease, asthma, or other allergic respiratory disease?.......... Yes No
    If yes, please list medications you are taking.___________________________________
6. Have you ever received a contrast agent or X-ray dye used for MRI, CT, or other X-ray?........ Yes No
7. Have you ever had an X-ray or MRI contrast agent allergic reaction?....................................... Yes No
8. Do you have any allergies to medications? _________________________............................ Yes No
9. Are you pregnant or suspect you may be pregnant?................................................................. Yes No
10. Are you breast feeding?............................................................................................................. Yes No
11. Date of last menstrual period? _____________ Post-Menopausal? __________

                                          MRI Hazard Checklist
The following items may be harmful to you during your MR scan or may interfere with the MR
examination. You must provide a “YES” or “NO” for every item. Please indicate if you have or have had
any of the following:
YES      NO
____ ____ Any type of electronic, mechanical, or magnetic implant?
____ ____ Cardiac Pacemaker?
____ ____ Aneurysm Clip?
____ ____ Implantable cardiac defibrillator?
____ ____ Neurostimulator?
____ ____ Any type of internal electrodes or wires?
____ ____ Cochlear Implant?
____ ____ Hearing Aid?
____ ____ Implanted drug pump (e.g., insulin, baclofen, chemotherapy, pain meds)?
____ ____ Spinal Fixation Device?
____ ____ Spinal Fusion Procedure?
____ ____ Any type of coil, filter, or stent?
____ ____ Artificial heart valve?
____ ____ Any type of ear implant?
____ ____ Penile Implant?
____ ____ Artificial eye?


                                                                                                                   Pete and Nancy Domenici Hall
                                                                                                                             1101 Yale Blvd NE
                                                                                                                        Albuquerque, NM 87106
                                                                                                                                  505-272-5028
                                                                                                                                   www.mrn.org
YES     NO
____   ____   Eyelid spring?
____   ____   Any type of implant held in place by a magnet?
____   ____   Any type of Surgical Clip or Staple?
____   ____   Medication Patch (e.g., nitroglycerine, nicotine, hormone)?
____   ____   Shunt?
____   ____   Artificial limb or joint?
____   ____   Tissue expander (e.g., breast)
____   ____   IUD?
____   ____   Removable dentures, false teeth, partial plate, braces or permanent retainer
____   ____   Surgical mesh?
____   ____   Body piercing? Location:__________________________________
____   ____   Wig, hair implants?
____   ____   Tattoos or tattooed eyeliner? Date of most recent tattoo:______________
____   ____   Radiation Seeds (e.g., cancer treatment)?
____   ____   Any metal implanted , inserted, or attached anywhere on or in your body (e.g., pins, rods
              screws, nails, plates, wires, or other items)?
____   ____   Jewelry?
____   ____   Any other type of implanted item?


                                         Please mark on the       RA/Technician Screening Participant:
                                         drawing indicating
                                         the location of any
                                         metal inside your
                                         body or site of                       PRINT NAME
                                         surgical operation.

                                                                                    DATE




If pregnancy test completed:        Results_________ RA/Tech initials_____

PARTICIPANT INFORMATION: You will be asked to change into a hospital gown or scrubs for your
MRI study. A locker will be provided for your personal belongings. Please remove all jewelry, hair pins,
bobby pins, barrettes, clips, etc. Remove all dentures, false teeth, and partial dental plates. Please
remove hearing aids, your watch, wallet, any credit or bank cards with a magnetic strip, pager, cell
phone, etc. Remove all body piercings. An MRI scan can be noisy, you will be wearing head phones to
protect your hearing during the scan.

_________________            _________________
Participant’s Height         Participant’s Weight


_______________________________             ___________________
Name of Participant (Please PRINT)           Date of Birth

_______________________________             ___________________
Signature of Participant                     Today’s Date

				
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posted:7/26/2011
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