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
Date
Legal Name*

First NameLast Name
Gender*
Date of birth*

MonthDayYear
Date
Now*

MonthDayYear
Date
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?

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

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

Other Medical History
YesNo
Please list any allergies or sensitivities here:
Please list details of ANY medication, herbal or natural supplements or topical creams here:
Certification

I certify that I have answered all questions to truthfully to the best of my knowledge and will advise my treatment provider if there are any changes to my health history in the future.
Name Printed*
Patient Signature*
Should be Empty:

MRI Safety Screening Questions