Safety Screening Form You must have JavaScript enabled to use this form. Magnetic Resonance (MR) Procedures If you prefer, you can download the Safety Screening Form and return the physical copy via email, fax, or call us for other options. Prior to your appointment please have reviewed the MRI Appointment Instructions. Name (first, middle, last) Email Phone Number Gender Male Female Age Date of Birth Year Year1903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Height Weight Please indicate if you have any of the following implanted devices in your body. Cardiac pacemaker or defibrillator Yes No Aneurysm Clip Yes No Neurostimulator, diaphragmatic stimulator, deep brain stimulator, vagus nerve stimulator, bone growth stimulator, spinal cord stimulator, or any biostimulator (in-place or removed) Yes No If you answer yes to any of the above questions please stop and talk directly with an MRI Coordinator by calling 240-313-9700 option 3. If all answers are No please proceed. Please answer the following questions. If uncertain of any answer below, please note in the additional comments section at the end of the form to discuss with the MRI coordinator when you are called to review and schedule. Surgery of any kind in the last six weeks Yes No If yes, list those surgeries and dates Are you Claustrophobic? Yes No IF YES, please contact your ordering provider for medication Personal history of cancer Yes No IF YES, Type Allergy to Gadolinium (MRI Contrast) Yes No IF YES, please contact your ordering provider to inform them you will need a Medrol Prep for this MRI Do you require the use of: Wheelchair/Walker/Cane or have any other special needs? Yes No Please describe: Injury by a metal object or foreign body (e.g. bullet, BB, shrapnel) Yes No If yes, explain Have you ever worked as a welder, machinist or with sheet metal? Yes No If yes, have you had x-rays of your eyes to clear you for MRI? Yes No If yes, Facility & Date performed If yes, have you worked with metal since this x-ray? Yes No Have you had an injury to your eye from a metal object or metallic foreign body? Yes No If yes, explain: Endoscopy or colonoscopy in last two months Yes No Females Only Is there a possibility that you are pregnant? Yes No Are you breast feeding? Yes No Please indicate if you CURRENTLY HAVE or HAVE EVER HAD any of the following: Surgically implanted medical devices Any type of electronic, mechanical or magnetic implant Yes No If yes, list type Any type of internal electrodes or wires Yes No Implanted drug pump (e.g., insulin, baclofen, chemotherapy, pain medicine) Yes No Artificial heart valve Yes No Spinal fusion/fixation device Yes No Implanted port (Port-a-Cath, Mediport, Powerport) Yes No Joint replacement (Hip, Knee, etc.) Yes No Ventricular Shunt Yes No Any other type of surgically implanted medical devices, removable medical devices or personal items not covered above? (Pins, Rods, Screws, Nails, Plates, Wires etc.) Yes No If yes, location Intrauterine device (IUD) or other implanted contraceptive Yes No Ear or Cochlear implant Yes No Any type of coil, filter or stent Yes No If yes, list type Eyelid spring and/or eyelid weight Yes No Artificial eye Yes No Any type of implant held in place by a magnet Yes No Penile implant Yes No Tissue Expander (e.g., breast) Yes No Surgical mesh Yes No If yes, location Artificial Limb Yes No If yes, which limb and which side of the body Removable medical devices Hearing aid Yes No Removable drug pump (e.g., insulin, Baclofen, Neulasta) Yes No Glucose monitoring Device (Freestyle or similar) Yes No If yes, type Medication Patch (eg. Nitroglycerine, Nicotine) Yes No Removable dentures, false teeth or partial plate Yes No Diaphragm, pessary Yes No If yes, type Have you recently ingested a “pill cam?” Yes No If yes, date “pill cam” was ingested If yes, date “pill cam” was ingested Year Year202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Personal The following items MUST be removed before entering the MRI Room: Body piercings and Jewelry Wigs, hair implants and hair accessories (e.g., bobby pins, barrettes, clips, extensions, weaves) Magnetic cosmetics and hair care (e.g., magnetic eyelashes, magnetic nail polish) Electronic monitoring or tagging equipment (e.g., ankle monitor) Fitness tracker/biomonitor (e.g., Fitbit) Metal-containing clothing material and/or underwear NOTE shiny threads in clothing contain metal Tattoos or tattooed eyeliner may contain metal that could heat up during the MRI Scan. Additional Comments Patient signature
You must have JavaScript enabled to use this form. Magnetic Resonance (MR) Procedures If you prefer, you can download the Safety Screening Form and return the physical copy via email, fax, or call us for other options. Prior to your appointment please have reviewed the MRI Appointment Instructions. Name (first, middle, last) Email Phone Number Gender Male Female Age Date of Birth Year Year1903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Height Weight Please indicate if you have any of the following implanted devices in your body. Cardiac pacemaker or defibrillator Yes No Aneurysm Clip Yes No Neurostimulator, diaphragmatic stimulator, deep brain stimulator, vagus nerve stimulator, bone growth stimulator, spinal cord stimulator, or any biostimulator (in-place or removed) Yes No If you answer yes to any of the above questions please stop and talk directly with an MRI Coordinator by calling 240-313-9700 option 3. If all answers are No please proceed. Please answer the following questions. If uncertain of any answer below, please note in the additional comments section at the end of the form to discuss with the MRI coordinator when you are called to review and schedule. Surgery of any kind in the last six weeks Yes No If yes, list those surgeries and dates Are you Claustrophobic? Yes No IF YES, please contact your ordering provider for medication Personal history of cancer Yes No IF YES, Type Allergy to Gadolinium (MRI Contrast) Yes No IF YES, please contact your ordering provider to inform them you will need a Medrol Prep for this MRI Do you require the use of: Wheelchair/Walker/Cane or have any other special needs? Yes No Please describe: Injury by a metal object or foreign body (e.g. bullet, BB, shrapnel) Yes No If yes, explain Have you ever worked as a welder, machinist or with sheet metal? Yes No If yes, have you had x-rays of your eyes to clear you for MRI? Yes No If yes, Facility & Date performed If yes, have you worked with metal since this x-ray? Yes No Have you had an injury to your eye from a metal object or metallic foreign body? Yes No If yes, explain: Endoscopy or colonoscopy in last two months Yes No Females Only Is there a possibility that you are pregnant? Yes No Are you breast feeding? Yes No Please indicate if you CURRENTLY HAVE or HAVE EVER HAD any of the following: Surgically implanted medical devices Any type of electronic, mechanical or magnetic implant Yes No If yes, list type Any type of internal electrodes or wires Yes No Implanted drug pump (e.g., insulin, baclofen, chemotherapy, pain medicine) Yes No Artificial heart valve Yes No Spinal fusion/fixation device Yes No Implanted port (Port-a-Cath, Mediport, Powerport) Yes No Joint replacement (Hip, Knee, etc.) Yes No Ventricular Shunt Yes No Any other type of surgically implanted medical devices, removable medical devices or personal items not covered above? (Pins, Rods, Screws, Nails, Plates, Wires etc.) Yes No If yes, location Intrauterine device (IUD) or other implanted contraceptive Yes No Ear or Cochlear implant Yes No Any type of coil, filter or stent Yes No If yes, list type Eyelid spring and/or eyelid weight Yes No Artificial eye Yes No Any type of implant held in place by a magnet Yes No Penile implant Yes No Tissue Expander (e.g., breast) Yes No Surgical mesh Yes No If yes, location Artificial Limb Yes No If yes, which limb and which side of the body Removable medical devices Hearing aid Yes No Removable drug pump (e.g., insulin, Baclofen, Neulasta) Yes No Glucose monitoring Device (Freestyle or similar) Yes No If yes, type Medication Patch (eg. Nitroglycerine, Nicotine) Yes No Removable dentures, false teeth or partial plate Yes No Diaphragm, pessary Yes No If yes, type Have you recently ingested a “pill cam?” Yes No If yes, date “pill cam” was ingested If yes, date “pill cam” was ingested Year Year202120222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Personal The following items MUST be removed before entering the MRI Room: Body piercings and Jewelry Wigs, hair implants and hair accessories (e.g., bobby pins, barrettes, clips, extensions, weaves) Magnetic cosmetics and hair care (e.g., magnetic eyelashes, magnetic nail polish) Electronic monitoring or tagging equipment (e.g., ankle monitor) Fitness tracker/biomonitor (e.g., Fitbit) Metal-containing clothing material and/or underwear NOTE shiny threads in clothing contain metal Tattoos or tattooed eyeliner may contain metal that could heat up during the MRI Scan. Additional Comments Patient signature
