[wr_row width=”boxed” background=”none” solid_color_value=”#FFFFFF” solid_color_color=”#ffffff” gradient_color=”0% #FFFFFF,100% #000000″ gradient_direction=”vertical” repeat=”full” img_repeat=”full” autoplay=”yes” position=”center center” paralax=”no” border_width_value_=”0″ border_style=”solid” border_color=”#000″ div_padding_top=”10″ div_padding_bottom=”10″ div_padding_right=”10″ div_padding_left=”10″ ][wr_column span=”span12″ ][wr_heading el_title=”MRI SAFETY SCREENING SHEET” tag=”h2″ text_align=”center” heading_margin_top=”25″ heading_margin_bottom=”25″ font=”inherit” enable_underline=”yes” border_bottom_style=”solid” appearing_animation=”0″ disabled_el=”no” ]MRI SAFETY SCREENING SHEET[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] Name Weight Height The Following Items May Interfere With MRI Imaging and Some Could Be Hazardous To Your Safety. ANY PREVIOUS IMAGING OF THE BODY PART BEING EXAMINED TODAY? YN IF YES, WHERE? WHEN? Please Check Yes or No To The Questions Below. Defibrillator or Pacemaker? YesNo Brain Surgery or Aneurysm Clips? YesNo Carotid Artery Vascular Clamp? YesNo Neuro or Spinal Stimulator? YesNo Artificial Heart Valve/Stent? YesNo Insulin or Drug Pump/IV Access Port? YesNo Cochlear (Ear) Implant? YesNo Penile Implant? YesNo Shrapnel or Bullets? YesNo Eye Injury or Surgery? YesNo Removable Dentures/Braces Dental Work YesNo Metallic Implant or Fragment YesNo Machinist or Metal Worker? YesNo Recent Tattoo? YesNo Hearing aids? YesNo Could You Be Pregnant? YesNo Are You A Nursing Mother? YesNo Contraceptive Diaphragm/IUD? YesNo Implanted Surgical Hardware (pins, rods screws) Artificial Joints or limbs? YesNo Medication Patch (Nitro, nicotine)? YesNo Shunt or SOPHY Pressure valve? YesNo Tissue expander? YesNo Wig or hair implants? YesNo Do you have a history of: Kidney Disease YesNo Allergic to MRI Contrast YesNo Diabetes YesNo Are you on Dialysis? YesNo Cancer YesNo On certain exams, we need to inject a contrast agent (Gadolinium) to improve the images that are created on your exam. This agent is safe; however. A small number of patients may experience headache, nausea, or vomiting. Serious reactions occur in less than 1% of patients. Is this exam being performed as a result of a motor vehicle accident? YesNo Date of injury I have read and understand the above. I give consent for this exam and the injection of gadolinium, if necessary. I certify that the above questions have been answered to the best of my ability. Patient’s/Guardian Signature: Date Reviewed By: Initials [/wr_text][/wr_column][/wr_row]