MRI Screening Form
Radiologic Technology Program
Name:
Weight:
Facility: Date: Age:
Do You Have or Have You Ever Had:
No Yes Aneurysm Clip(s) No Yes Body Piercing(s)
No Yes Pacemaker, Defibrillator, or Loop Recorder No Yes Tattoo or Permanent Makeup
No Yes Pacemaker/Defibrillator Wires No Yes Claustrophobia
No Yes Neurostimulator No Yes Catheter (Swan-Ganz, Foley, etc.)
No Yes Heart Valve
No Yes Insulin or Medication Pump
No Yes Stents, Filters, or Coils
If yes, where in body?
What year was it placed?
No Yes Medication Patches (Nicotine, Fentanyl, etc.)
No Yes History of Cancer
No Yes Shunt (Spinal or Intraventricular)
If yes, what kind?
No Yes Ear or Eye Implant
No Yes Kidney or Liver Problems
No Yes Bone Stimulator
No Yes Diabetes
No Yes Any Metal Fragments/Shrapnel No Yes Ever Been on Dialysis
No Yes Had Metal Particles in Eyes No Yes Hypertension
If yes, have eye x-rays been done? No Yes Kidney/Liver Transplant
No Yes Dentures/Partials No Yes Asthma
No Yes Hearing Aids No Yes X-ray, CT, or MRI Contrast
No Yes Any Type of Prosthesis (Eye, Penile, etc.) Reaction/Allergy
No Yes Surgical Staples or Clips
No Yes Joint Replacement (Knee, Hip, etc.)
If you answered YES to any question, please provide additional information.
Signature:
MRI Technologist’s Signature:
Developed 10-2014
Female Patients Only:
No Yes Pregnant or Possibly Pregnant
No Yes Breastfeeding
No Yes IUD or Diaphragm
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