MRI Safety Questionnaire

    MRI SAFETY QUESTIONNAIRE

    Prior to the examination, this form must be completed by the patient or guardian and signed. Some of the following items may be hazardous in the scanner.

    TitleMrMrsMsMiss



    Referral upload*(Click "Choose File" button below to attach or take a photo of your referral for upload):
    Please ensure you capture the entire referral form.


    Have you ever had surgery of your:
    Head
    YesNo
    Heart
    YesNo
    Inner Ear
    YesNo
    Inner Ear
    YesNo

    Renal Transplant
    YesNo

    Do you have any of the following?
    Neural Stimulator
    YesNo
    Cardiac pacemaker or pacing wires or Cardiac Defibrillator
    YesNo


    Aneurysm clips (surgical clips on arteries in your brain)
    YesNo

    Ear lmplants
    YesNo

    Eye Implants
    YesNo
    Stents/Heart Valves
    YesNo
    Bowel Clips(any recent bowel surgery?)
    YesNo
    Tissue Expanders (Breast or Penile)
    YesNo
    Hearing aid (to be removed before scan)
    YesNo
    Dentures (to be removed before scan)
    YesNo
    Magnetically implanted dental devices
    YesNo
    Any other magnetic, electronic or metallic implants or devices
    YesNo

    If yes, please list:

    Do you wear any medication patches?YesNo
    Have you ever had metal fragments in your eyes?YesNo
    Do you have any tattoos less than 4 weeks old (including cosmetic)YesNo
    Are you a diabetic? YesNo
    Have you had a recent blood test for kidney function? YesNo
    Are you pregnant or breastfeeding? YesNo
    Have you ever had an allergic reaction to MRI contrast? YesNo
    Do you suffer from claustrophobia? YesNo
    Have you ever had an MRI scan before?YesNo
    If yes;

    Where

    When
    Who has the images?
    I the patient or substitute decision maker, confirm that I have read and/or been read and understand these questions and have answered them correctly.