MRI Safety Screening Questionnaire

MRI Safety Screening Questions

Please complete this form if you are requesting an MRI
The following questions must be answered by all patients as part of safety screening prior to MRI exam. Please answer all questions.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Name

First NameLast Name
Gender
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Now

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age (calculated, office use)
BC Care Card / Personal Health Number
Height (indicate cm or in)
Weight (indicate kg or lb)
Your Tel No:
Your email:
example@example.com
Family doctor's name:
What is the reason for the MRI request?
Do you have ANY allergies to medications, food, latex, or other substances?
Please list any allergies or sensitivities here:
MRI Safety Screening Questions

Safety Screening. Please indicate if any of the following applies to you:

Rows	YES	NO	Unsure
Cardiac Pacemaker / defibrillator
Cerebral Aneurysm Clip
Internal Electrodes or Wires
Eye or Ear Implant
Metallic Foreign Body in Eye or anywhere in your body
Shrapnel and/or Bullet
Intravascular Coil, Stent or Filter
Breast tissue expander
Implanted Infusion Pump or Stimulator
Pregnant or trying to conceive
Breastfeeding
Claustrophobic
Neurostimulator
Age over 60
Diabetes
High blood pressure
Liver Disease
Liver Transplant
PICC line / IV line
Other

Certification

I certify that I have answered all questions to truthfully to the best of my knowledge and will advise my treatment provider immediately if there are any changes to my health which would change any of these answers.
Name Printed
Patient Signature
Should be Empty:

MRI Safety Screening Questions