Mri safety.pdf

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: ________________________ Requistioning investigator_____________________ For MRI Offi
ce Use Only
Subject Name______________________________ Procedure______________________________________ Subject ID Number_________________________ Diagnosis______________________________________ Principal Investigator________________________ Clinical History_________________________________ Hazard Checklist for MRI Personnel
_______ _______Foley catheter with temperature sensor


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