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MRI SCREENING QUESTIONNAIRE
Red- Show stoppers
Green- Go
Orange- Precautions

 

1.  Do you have a cardiac pacemaker?                                           Yes          No           Don’t Know                                                                       

• If  Yes person may not receive MR, an alternate plan of action is recommended

 

2.  Do you have an implantable cardio defibrillator?         Yes          No           Don’t Know

• If  Yes person may not receive MR, an alternate plan of action is recommended

               
3.  Do you have a stent(s) or cardiac wires?                          Yes          No           Don’t Know

• If Yes,  (schedule 4 to 5 working days out pending research of stents) Patient must bring stent card to

 Radiology department within 24 hours.
 

4.  Do you have cochlear implants in your inner ear? Yes          No           Don’t Know

• If  Yes person may not receive MR, an alternate plan of action is recommended

 

5.  Do you have a history of kidney disease or currently on kidney dialysis? Yes          No           Don’t Know

• If  Yes person may not receive MR, an alternate plan of action is recommended

 

6.  Have you ever had any head surgery requiring aneurysm clips?  Yes          No           Don’t Know

• If Yes,  (schedule 4 to 5 working days out pending research of stents) Patient must bring stent card to

 Radiology department within 24 hours.

7.  Have you ever had any type of surgery? Yes          No           Don’t Know

• If yes, please list________________________________________________________

 

8.  Do you have any surgically implanted metal of any type in your body?   Yes          No           Don’t Know
               

• If yes, please list________________________________________________________

9.  Do you have any metal pins, prosthesis or metal objects in, or attached to, your body?  Yes          No         Don’t Know

• If Yes, Please list_________________________________________ See MRI radiology Technologist for further evaluation.

 

10.  Have you ever been exposed to metal fragments that could be lodged in you eyes or body? Yes          No       Don’t Know

• If yes, schedule the patient 4-5 days out, instruct the patient that they require additional screening prior to the exam being done. (a screening sinus x-ray is required before examination can be performed, the ordering physician needs to order a  x-ray for sinus exam and report to the radiology dept with request for sinus x-ray during normal working hours).

11.  Do you have a hearing aid, middle inner ear prosthesis or dentures? Yes          No          Don’t Know

• If yes, the patient will be required to remove them prior to undergoing the exam.

12.  Do you have any type of electronic device (stimulator or pump) implanted in your body? Yes        No        Don’t Know

• If yes (see unless), person may not receive MR, an alternate plan of action is recommended. Unless patient can produce card that states that equipment is MRI safe.

 

13.  Do you have or have you ever had tattoos, tattooed eyeliner, lipliner or body piercing? Yes          No        Don’t Know
               

• The exam can still be performed but precautions must be explained to the patient.

14. Do you wear a medicine skin patch on your body (e.g. nitroglycerin, nicotine, or hormone)? Yes          No           Don’t Know

15.  Have you ever had a reaction tom a contrast agent used for MRI, CT, or X-ray? Yes          No           Don’t Know

• The exam can still be performed but precautions must be explained to the patient

 

16.  Do you have a history of panic attacks or a fear of enclosed or narrow places? Yes          No           Don’t Know

• The exam can still be performed but medications must be ordered for this exam to be performed?  

 
17.  If you are a woman – are you pregnant, or is it possible that you might be pregnant? Yes          No           Don’t Know

• If yes we must get consent from the attending physician and the patient.

 

• 18.  If you are a woman – are you breastfeeding? Yes          No           Don’t Know         
• Do not recommend contrast for these patients.  If this procedure is conducted with contrast, the patient will not be allowed to breast feed for 48 hours.

19.  Do you have any magnetically-activated implants or devices?  Yes         No          Don’t Know

• If yes, the MRI procedure could affect the operation of the device.  Patients must be advised and get clearance from physician.

 

20.  Do you have any breathing problems or motion disorders? Yes          No           Don’t Know

• If yes, List:________________________
• Do you require medication in order for this exam to be performed? Yes          No           Don’t Know

 

21. Do you have a neurostimulation system? Yes          No           Don’t Know
 

• IF yes, the device must be removed prior to performing the MRI.

22.  Diabetes:       Yes         No, Insulin Dependent:  Yes         No         Are you taking Glucophage?  Yes         No       

• If patient is taking Glucophage, instruct patient that they are to delay taking medication 72 hours after the administration of contrast material)

 

22.  Are there any other items or devices you believe we should know about prior to performing the procedure – if yes, please describe:

________________________________________________________________________________________________________