MRI SCREENING FORM
Patient Name: ______________________________DOB: _____________ Weight: ______________
Sex: M / F
THESE ITEMS CAN INTERFERE WITH MR IMAGING AND SOME CAN BE HAZARDOUS TO YOUR SAFTEY
Please check Yes or No to each item
Have you ever had: An injury to your eye involving metal?
YES
NO
A metallic fragment or foreign body in your head, face, neck or body?
YES
NO
If yes to either questions above, were you tested to ensure all metal was removed?
YES
NO
SURGICAL IMPLANTS
YES
NO
YES
NO
Cardiac Pacemaker
Aneurysm Clips
Pacemaker Wires
Neurostimulator
Electronic Implant or Device
Implanted Cardiac Defibrillator (ICD)
Spinal Cord Stimulator
Bone Fusion or Bone Growth Stimulator
Cochlear, Otologic, or Ear Implant
Tissue Expander (Breast)
Internal Electrodes or Wires
Magnetically-activated Implant or Device
Eyelid Spring or Wire
Swan-ganz Thermodilution Catheter
Cardiac Stent
Clips in Blood Vessel
Artificial Heart Valves
Implanted Drug Infusion Device/Pump
Endoscopy with Camera Pill
Venous Umbrella
Coil, Filter, Wire in Blood
Pessary or Bladder Ring
Shunt (spinal or cranial)
Any Metallic Fragment or Foreign Body
Prosthesis (Eye, Penile, etc.)
Transdermal Medication Patches (Nitro, Nicotine)
Radiation Seeds or Implants
Bone/Joint Pin, Screw, Nail, Wire, Plate, etc.
Artificial Limb, Joint Replacements
Harrington Rods (spinal)
Tens Units
Wire Mesh Implants
Vascular Access Port or Catheter
Surgical Staples, Clips or Metallic Sutures
IUD or Diaphragm
Tattoo or Permanent Makeup
Body Piercing Jewelry
Dentures or Partials
Hearing Aid
Claustrophobic
IMPORTANT INSTRUCTIONS
Before entering the MR environment or MR system room, you must remove ALL metallic objects including hearing
aids, dentures, partial plates, keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercings,
money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing
with metal fasteners and clothing with metallic threads. Consult the MRI Technologist BEFORE entering the MR
exam room if you have any questions. The MR system magnet is ALWAYS on.