Magnetic Resonance (Mr) Procedure Patient Screening Form
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1
2MAGNETIC RESONANCE (MR) PROCEDURE PATIENT
SCREENING FORM
Date: ______/______/_______
Patient Number: __________________________
Nov. 2015
Name:
Age:
Height:
Weight:
Male
Female
Date of Birth:
/
/
Body Part to be Examined:
The MR system has a very strong magnet field that may be hazardous to individuals entering the MR
environment or MR system room if they have certain metallic, electronic, magnetic, or mechanical
implants, devices or objects. Therefore, all individuals are required to fill out this form BEFORE
entering the MR environment or MR system room.
BE ADVISED, THE MR SYSTEM MAGNET IS ALWAYS ON.
YES
NO
1. Do you have a cardiac pacemaker?
2. Do you have any metal in your body?
3. Do you have an electronic implant or device?
4. Do you have a cochlear implant or implanted hearing device?
5. Have you had prior surgery or an operation (e.g., arthroscopy, endoscopy, etc.) of any kind?
If yes, please indicate the date and type of surgery:
Date: ____/____/____
Type of Surgery: _____________________________
6. Have you experienced any problem related to a previous MRI exam or MR procedure?
7. Have you had an injury to the eye involving a metallic object or fragment
sh
(e.g., metallic slivers,
avings,
If Yes, please describe: _________________________________
foreign body, etc.)?
8. Have you ever been injured by a metallic object or foreign body
(e.g., BB, bullet, shrapnel, etc.)?
If Yes, please describe: ________________________________________________
9. Are you currently taking or have you recently taken any medication or drug?
If Yes, please list: _____________________________________________________
10. Are you allergic to any medication?
If Yes, please list: _____________________________________________________
11. Do you have a history of asthma, allergic reaction, respiratory disease, or reaction to a medium or dye
used for an MRI, CT, or X-ray examination?
12. Do you have anemia or any disease(s) that affect your blood, a history of renal (kidney) disease, or
seizures? If Yes, please describe: ___________________________________
FOR FEMALE PATIENTS
13. Date of last menstrual period: ____/____/____
14. Are you pregnant or experiencing a late menstrual period?
15. Are you currently breastfeeding?
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