Smart MRI screening Questionnaire

MRI Screening Questionnaire
Patient Name*
Medical Record #
Date of Birth*

MonthDayYear
Date
Approx. Date of last MRI (if you don't know it please disregard)

MonthDayYear
Date
MaleFemale
Age
Height
Weight
This questionnaire is designed to assist us in determining if it is safe for you to undergo a Magnetic Resonance Imaging procedure. It is important that you answer all of the following questions.

If you don't understand any question, please ask for assistance.
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
YesNoI don't Know
accepted
Technologist's Initials Only:
Should be Empty: