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MRI Checklist Form
Please indicate if the patient has any of the following.
Patient cannot have an MRI done if any of the top 3 questions is answered with a 'YES'.
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* Indicates required question
Do you have a Pacemaker?
*
Yes
No
Do you have an Implanted Cardiac Defibrillator
*
Yes
No
Do you have a Cochlear implant
*
Yes
No
Are you on Dialysis, have Renal failure or renal insufficiency?
(Will require additional assessment by radiologist if patient checks "YES" to this question)
*
Yes
No
Are you claustrophobic?
*
Your answer
Do you have anxiety/emotional distress?
*
Yes
No
Small Bowel Endoscopy capsule. If yes, explain:
*
Your answer
Heart Surgery/Heart Valve, stents.
*
Yes
No
Shunts/Stents/Intravascular coil
*
Yes
No
Ear surgery
*
Yes
No
Eye Surgery/Implants/Retinal buckle
*
Yes
No
Injury to the eye involving metal or metal shavings
*
Yes
No
Neurostimulator/Biostimulator/Bone growth Stimulator
*
Yes
No
Do you have any Metal Mesh Implants/Wire Sutures/Wire Staples/Internal electrode
*
Yes
No
Do you have any electrical, mechanical, or magnetic implants? If yes what type:
If you do not have any of these implants please type "None" into the text box.
*
Your answer
Do you have an implanted drug infusion pump or an insulin pump?
*
Yes
No
Do you have a Vascular Access Port?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Do you have any
Orthopedic pins, screws, rods, etc.
*
YES
No
Do you have
Dentures (partials or dental implants), or Braces?
*
Yes
No
Do you have history of
Gunshot wounds, shrapnel, or BB's.
*
Yes
No
Do you have an
IUD
or
Diaphragm
?
*
Yes
No
Do you have a history of
Cancer
or
Tumors?
If yes, when did it take place, and where in the body?
If you have not had any history of cancer or tumors type "N/A" into the text box.
*
Your answer
Are you or have you ever received Radiation Therapy or Chemotherapy?
*
Yes
No
Previous Back Surgery
(Low Back or Cervical)
?
If yes, when did it take place and what levels
?
If you have not had previous back surgery please type "N/A" in the text box.
*
Your answer
Do you wear a hearing aid
(please remove it before your exam if you do wear one).
*
Yes
No
Do you have pins in hair, hair extensions, hair pieces or a wig?
*
Yes
No
Do you have tattoos or permanent makeup?
*
Yes
No
Are you using any skin patches?
For Example: Nitroglycerin, Nicotine Patches to Stop Smoking, Pain Patches etc.
*
Yes
No
Do you have a latex Allergy
*
Yes
No
Are you taking medications (vitamins count as well)?
Please list them in the text box along with the amount prescribed, dose, and how often they are taken.
If you are not taking any medications please type "N/A" in the text box.
*
Your answer
Any allergies? Please list them in the text box.
Seasonal allergies count.
If you are not aware of having any allergies please type "N/A" in the text box.
*
Your answer
Body piercings? If yes, what types?
If you do not have any please type "N/A" in the text box.
*
Your answer
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