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MRI Safety Screening Form - Amended - 30NOV2016

1. This document is an MRI safety screening form that collects important medical information from a patient before undergoing an MRI scan. 2. It asks questions about the patient's medical history including any prior MRIs, allergies, implants, surgeries, and for women, pregnancy status. 3. The form also informs the patient that metallic objects cannot be brought into the MRI room due to the strong magnet and risks interference or injury. The patient must sign confirming they understand this safety information.

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FC LOON
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2K views1 page

MRI Safety Screening Form - Amended - 30NOV2016

1. This document is an MRI safety screening form that collects important medical information from a patient before undergoing an MRI scan. 2. It asks questions about the patient's medical history including any prior MRIs, allergies, implants, surgeries, and for women, pregnancy status. 3. The form also informs the patient that metallic objects cannot be brought into the MRI room due to the strong magnet and risks interference or injury. The patient must sign confirming they understand this safety information.

Uploaded by

FC LOON
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Affix Patient Label

Name:
NRIC:
DOB:
Race: Sex:
Neuroradiology Department Case No:
MRI SAFETY SCREENING FORM
IMPORTANT: The Magnetic Resonance Imaging (MRI) room contains a very strong magnet and it is always switched on. Some
metallic objects can interfere with MRI or can be hazardous to you. Before you enter, you must remove all your metallic and
electronic items (eg hearing aids, keys, cell phones, watches, jewellery and eye make up).

Please check the following carefully.


1. Have you ever had an MRI scan before? No Yes
Details (if yes): ___________________________________________
2. Do you have any history of allergy to the dye (contrast agent) injected for MRI scans? No Yes
Details (if yes): ___________________________________________
3. Do you suffer from claustrophobia (fear of enclosed spaces)? No Yes
Details (if yes): ___________________________________________
4. Do you suffer from kidney failure? No Yes
Details (if yes): ___________________________________________
5. Any implant inside your body? No Yes

Heart or Major Vessel Electronic or Metallic Brain or Spine


No Yes No Yes No Yes
Surgery / Intervention Implants / Foreign Bodies Surgery
Heart Valve Replacement Cochlear Nerve Stimulator
Eye (including coloured
Vessel Stent / Filter Aneurysm Clip
contact lenses)
Pacemakers, Automatic
Implantable Cardioverter
Vascular Access Port or
Defibrillators, other Cardiac Spinal / Brain
Catheter /
Implantable Electronic Devices Shunt
Drug Infusion Device
such as cardiac resynchronization
devices and loop recorders.
Bone, Spine or Joint Surgery No Yes Skin No Yes Others No Yes
Metallic Plate / Screw / Nail / Wire /
Staples or Sutures IUCD
Pin
Joint prosthesis Tattoos Camera Pill

Please specify object(s) where indicated (Yes) or if not listed above:


_________________________________________________________
6. Do you have any other surgeries? No Yes
Details (if yes): ___________________________________________
For Female Patient Only:
 Are you pregnant? No Yes
Date of last menstrual period (LMP)? ________________________
 Are you currently breastfeeding? No Yes

I have answered the above questions to the best of my knowledge.


I have fully understood the contents of this document. In particular, I understand that possible injury could result if I
withhold vital information.
By signing this document, I confirm that I have fully understood the contents.

______________________________ ____________________________________
Patient's Signature / Date OR Signature and Name of Guardian / Date
OR
Signature and Name of Clinician In-Charge / Date
FOR OFFICIAL USE ONLY:________________________________________________________________________________________

Form Completed By Staff: For MRI scan that requires intravenous gadolinium contrast:
Latest Serum Creatinine: ______µmol/L (Date Taken:_______)
___________________________________ eGFR:_____________ Body weight: _____________
Signature and Name / Date

NRD-MRI-01-01 DEC16

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