Attch 7-MRI Screening Form_Final.pdf

Department of Veterans Affairs MRI Screening Form

LAST NAME, FIRST NAME, MI

MANN-GRANDSTAFF VAMC

SPOKANE, WASHINGTON

03/2014

MRI SCREENING FORM

(DIAGNOSTIC IMAGING SERVICE)

OP FORM 668-RAD-004 (2014)

WARNING: Certain implants, devices, or objects may be hazardous to you and/or may interfere with the procedure. DO NOT ENTER the MR system room or MR environment if you have any question or concern regarding an implant, device or object. Consult the MRI Technologist or Radiologist BEFORE entering the MR system room. The MR system magnet is ALWAYS ON.

IMPORTANT INSTRUCTIONS: Before entering the MR environment or MR system room, you must remove ALL metallic objects including phone, eyeglasses, hair pins, barrettes, jewelry, body piercing, watch, safety pins, paper clips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, and clothing with metallic threads.

Please indicate if you have any of the following:

Yes No Aneurysm Clip(s) Please mark the figure(s) below with the location of any implants or metal inside of or on your body Yes No Cardiac Pacemaker

Yes No Implanted Cardioverter Defibrillator (ICD)

Yes No Electronic implant or device

Yes No Magnetically-activated implant or device

Yes No Neurostimulation system

Yes No Spinal cord stimulator

Yes No Bone growth / bone fusion stimulator

Yes No Cochlear, otologic or other ear implant

Yes No Any type of prosthesis (eye, penile, etc.)

Yes No Heart valve prosthesis

Yes No Eyelid spring or wire

Yes No Artificial or prosthetic limb

Yes No Metallic stent, filter or coil

Yes No Shunt (spinal or intra-ventricular)

Yes No Vascular access port and/or catheter

Yes No Radiation seeds or implants

Yes No Swan-Ganz or thermo-dilution catheter

Yes No Medication patch (Nicotine, Nitroglycerine)

Yes No Any metallic fragment or foreign body

Yes No Wire mesh implant

Yes No Tissue expander (e.g., breast)

Yes No Surgical staples, clips, or metallic sutures

Yes No Joint replacement (hip, knee, etc.)

Yes No Bone/joint pin, screw, nail, wire, plate, etc.

Yes No IUD, diaphragm, or pessary

Yes No Dentures or partial plates

Yes No Tattoo or permanent makeup

Yes No Body piercing jewelry

Yes No Hearing Aid

Yes No Other implants:

Signature of Person Completing Form Relationship Date

Form Reviewed by: Cleared to Enter?

Yes No

Date

Self

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