MRI Safety and Screening Form Signature: Type or Draw × Type Mode On. Draw Mode On. Type It Draw It Clear Rev 02/12/2016 MRI SAFETY & SCREENING FORM TECH FORM NAME:M/F:DOB:WEIGHT: PLEASE ANSWER THE FOLLOWING QUESTIONS CAREFULLY: Select YES or NO Have you had a previous MRI of any kind? YES NO If yes, date/year?Have you ever been a machinist, welder, or sheet metal worker? YES NO Have you ever been hit in the face or eye with a piece of metal (BB, shavings, filings)? YES NO Ever had a piece of metal removed from your eye? YES NO Have you ever had any type of surgical procedure (operation)? YES NO If Yes, what kind and when? Please select any of the following items that may be in body: PACEMAKER OR DEFIBRILATOR YES NO Spinal Cord Stimulator or Neuro Stimulator of any kind [Tens Unit] YES NO Cardiac Stents [Heart] YES NO Patch of any type Artificial Heart Valve ANEURYSM [Clip, Coil, or Stent] of any kind [Brain, Aorta, Carotid, Artery] YES NO If so, where in the body?STENT in any part of the body? [Carotid Artery/Neck, Legs, or Arms] YES NO Ear implants of any kind YES NO Hearing aids (Internal or External) Electrical stimulator for Nerves or Bones YES NO Coil or filter of any type Orthopedic hardware of any kind [screws, pins, plates, or rods] YES NO Any implant of any kind? YES NO If so, what?SHUNT of any type YES NO Penile Prosthesis Prosthesis of any type. YES NO If so, where?Drug/ Insulin Pump YES NO Internal External (can be removed) Metal to any part of the body YES NO (including bullet, bb, shavings, filings, & Shrapnel metals) The following items may be damaged or pose a threat to anyone in the magnetic suite. These items need to be removed prior to entering the magnet room. Dentures or Partials Jewelry Watch Credit Cards Safety pins Bobby pins or hairpins Wigs or hairpieces Drug Patches FOR FEMALE PATIENTS Any chance of you being PREGNANT? YES NO Are you breast feeding? YES NO I attest that the answers I have given on this form are true and correct to the best of my knowledge. Open MRI of SANPC is not responsible for any valuables or objects brought into this facility. I have read this form and understand its contents. I have been given the opportunity to ask questions and have had those questions answered to my satisfaction. Patient Name (PRINT)DateSignature of patient or guardian Pre-Screening Form Appointments for MRI Scans Patient Name:Date: Pacemaker / Defibrilator YES NO Heart Surgery / STENT YES NO Brain Surgery / Aneurysm Surgery YES NO Stents – ANY YES NO Hearing Implant / Ear Surgery YES NO Metal Implants YES NO Stimulator Implants YES NO Eye Surgery / Implant YES NO Metal to eyes (Any experience of metal grinding) YES NO Metal to any part of body (bullet, BB, shavings, filings) YES NO Claustrophobic YES NO Pregnant YES NO Currently taking any blood thinners (i.e. Plavix, aspirin, coumadin, etc…) YES NO If none of the above, please initial stating all questions above were answered with NO.Initials Patient Signature Print