MRI Patient History & Screening Form

Male    Female
Yes No

If you answered yes DO NOT have this test performed. Please see a staff member immediately.

Reason you are here today? (Explain your medical problem in detail .... What is the problem? Where is the problem? How long have you had this problem?)

Yes No

Motor Vehicle Accident Work Other

Yes No

Do you have or have you ever had any of the following?

Heart Surgery/Heart Valve
Brain Surgery
Brain Aneurysm Clips
Injury to the eye involving metal or metal shavings
History of kidney disease
Shunts/Stents/Intravascular Coil
Eye Surgery/implants
Orthopedic pins, screws, rods, etc.
Neurostimulator/Biostimulator/Bone Growth Stimulator
History of cancer or tumors
Previous Back Surgery (Low Back or Cervical)
Ear Surgery/Cochlear Implants/Hearing Aids
Metal Mesh Implants/Wire sutures/wire staples/internal electrode
Any electrical, mechanical, or magnetic implants.
Tissue Expander? (eg. Breast)
Any Prosthesis?
Drug infusion pump/insulin pump
Glucose Monitor (attached to skin)
Penile implant
Are you Pregnant/Have IUD/Pessary?
Tattoo's/permanent make-up/body piercing
Dentures, partials or dental implants
Gunshot wounds, shrapnel, BB's
Do you have pins in hair, hair extensions, hair pieces or a wig?

List any drug allergies:

List previous surgeries:

Medications presently taking (including medication patches):

Yes No
Yes No

I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that I am not pregnant at this time nor do I have a pacemaker or brain aneurysm clip.