SAFETY SCREENING FORM FOR MAGNETIC RESONANCE (MR) PROCEDURES
Have you ever had an injury from a metal object in your eye
Name (first middle last)_________________________
(metal slivers, metal shavings, other metal object)?
Female  Male  Age_____Date of Birth___________
if yes, did you seek medical attention?________ if yes,
Why are you having this examination (medical problem)?
Do you have a history of kidney diseases, asthma, or other
Have you ever had an MRI examination before and had a
If yes, please list drugs____________________________
If yes, please describe______________________
Have you ever had a surgical operation or procedure of any
Have you ever had an X-Ray dye or magnetic resonance
imaging (MRI) contrast agent allergic reaction?
If yes, list all prior surgeries and approximate dates:
If yes, please describe______________________________
Have you ever been injured by a metal object or foreign body
Are you pregnant or suspect you may be pregnant?
If yes , please describe______________________
Date of last menstrual period______ Post-menopausal?
MR Hazard Checklist
Please mark on the drawing indicating the location of any
____ ____ Any type of electronic, mechanical or magnetic
metal inside your body or site of surgical operation.
The following items may be harmful to you during
your MR scan or may interface with the MR examination. You
must provide a “ yes” or “ no” for every item. Please indicate
if you have or have had any of the following:
_______ _______Implantable cardiac defibrillator
_______ _______Any type of internal electrodes or wires
_______ _______Implanted drug pump (e.g., insulin
_______ _______Any type of coil, filter, or stent
_______ _______Any type of metal object (e.g., shrapnel,
Safe MR Practices
_______ _______Any type of implant held in place by a
_______ _______Any type of surgical clips or staple
_______ _______Intavenous access port (e.g., Broviac, Port-
_____ _______Tattoos or tattooed eyeliner
_____ _______Radiation seeds (e.g., cancer treatment)
_______ _______Medication patch (e.g., nitroglycerine,
_____ _______Any implanted items (e.g., pins, rods,
_____ _______Any hair accessories (e.g., bobby pins,
_______ _______Tissue expander (e.g., breast)
_____ _______Any other type of implanted item
_______ _______Removable dentures, false teeth, or partial
Instructions for the Patient
1. You are urged to use the earplugs or headphones that
9.Use gown, if provided, or remove all clothing with
we supply for use during your MRI examination
since some patients may find the noise level
unacceptable, and the noise levels may affect your
I attest that the above information is correct to the best of
my knowledge. I have read and understand the entire
2. Remove all jewelry (e.g. necklaces, pins, rings).
contents of this form, and I have had the opportunity to
3. Remove all hairpins, bobby pins, barrettes, clips etc.
ask questions regarding the information on this form.
4. Remove all dentures, false teeth, partial dental plates
Names & signatures:
7. Remove your watch, pager, cell phone, credit and
bankcards, and all other cards with a magnetic strip.
MRI faculty incharge: ________________________
For MRI Offi
ce Use Only
Subject ID Number_________________________
Hazard Checklist for MRI Personnel
_______ _______Foley catheter with temperature sensor
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Regular Article Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry Lisa Cosgrove a Sheldon Krimsky b Manisha Vijayaraghavan a a University of Massachusetts, Boston, Mass. , and b Tufts University, Medford, Mass. , USA Key Words cies (22%) and speakers bureau (16%). Conclusions: Our Confl icts of interest ؒ Ethics ؒ Financial interests ؒ in