MRI Patient Screening Questionnaire and Consent Form
SURNAME FIRST NAME
DATE OF BIRTH CHI
HEIGHT WEIGHT
ADDRESS HOME TEL
Question Yes No
1. Do you have a CARDIAC PACEMAKER or artificial HEART VALVE?
2. Have you ever had any operations on your CHEST, HEART, HEAD or EYES?
3. Do you have an ANEURYSM CLIP, COCHLEAR IMPLANT or SHUNT?
Have you ever in your life had an accident with metal, where metal
4.
fragments have gone into your eyes or body?
Are you wearing a MEDICAL patch e.g. Pain, Cardiac, HRT, Nicotine,
5.
Fentanyl?
6. LADIES: Could you be pregnant? Or are you breast-feeding?
If you answer YES to any of the questions 1-6 please contact the MRI
department.
7. Have you ever had any surgery?
8. Have you had any surgery in the last 2 months?
9. Do you have a HEART CONDITION or KIDNEY DISORDER?
10. Are you currently EPILEPTIC or DIABETIC?
Are you wearing DENTURES, DENTAL PLATE, CONTACT LENSES or
11.
HEARING AID?
12. Do you have any tattoos or piercings?
Do you have any metallic, electronic or foreign metallic objects in or
13.
attached to your body other than those mentioned above?
I UNDERSTAND THE MRI EXAMINATION. I ALSO UNDERSTAND THE ABOVE QUESTIONS AND GIVE
PERMISSION FOR THE USE OF INTRAVENOUS CONTRAST AGENT IF IT IS DEEMED NECESSARY.
I CONFIRM I HAVE REMOVED ALL METAL FROM MY PERSON.
SIGNATURE ......................................................... DATE..........................................
(Or signature of responsible adult)
RADIOGRAPHER................................................... DATE..........................................
LOT1542 Version 2.1 Author: MRI Safety Expert Approved by: Clinical Policy, Documentation & Information Group
Approved: Oct 2017 Review: Oct 2020
SURNAME FIRST NAME
DATE OF BIRTH CHI
HEIGHT WEIGHT
ADDRESS HOME TEL
Question Yes No
1. Do you have a CARDIAC PACEMAKER or artificial HEART VALVE?
2. Have you ever had any operations on your CHEST, HEART, HEAD or EYES?
3. Do you have an ANEURYSM CLIP, COCHLEAR IMPLANT or SHUNT?
Have you ever in your life had an accident with metal, where metal
4.
fragments have gone into your eyes or body?
Are you wearing a MEDICAL patch e.g. Pain, Cardiac, HRT, Nicotine,
5.
Fentanyl?
6. LADIES: Could you be pregnant? Or are you breast-feeding?
If you answer YES to any of the questions 1-6 please contact the MRI
department.
7. Have you ever had any surgery?
8. Have you had any surgery in the last 2 months?
9. Do you have a HEART CONDITION or KIDNEY DISORDER?
10. Are you currently EPILEPTIC or DIABETIC?
Are you wearing DENTURES, DENTAL PLATE, CONTACT LENSES or
11.
HEARING AID?
12. Do you have any tattoos or piercings?
Do you have any metallic, electronic or foreign metallic objects in or
13.
attached to your body other than those mentioned above?
I UNDERSTAND THE MRI EXAMINATION. I ALSO UNDERSTAND THE ABOVE QUESTIONS AND GIVE
PERMISSION FOR THE USE OF INTRAVENOUS CONTRAST AGENT IF IT IS DEEMED NECESSARY.
I CONFIRM I HAVE REMOVED ALL METAL FROM MY PERSON.
SIGNATURE ......................................................... DATE..........................................
(Or signature of responsible adult)
RADIOGRAPHER................................................... DATE..........................................
LOT1542 Version 2.1 Author: MRI Safety Expert Approved by: Clinical Policy, Documentation & Information Group
Approved: Oct 2017 Review: Oct 2020
