MRI Safety Checklist
Location of Appointment
*
Auburn
Campsie
Norwest
Rouse Hill
First Name
*
Last Name
*
DOB
*
Weight
*
Height
*
Female Patients:
*
Yes
No
Any possibility you may be pregnant
Yes
No
Do you have any intrauterine devices
Yes
No
Have you taken any for of sedative today
Yes
No
Have you ever:
Yes
No
Had heart surgery?
Yes
No
Had brain surgery?
Yes
No
Had ear surgery?
Yes
No
Yes
No
Had metal in your eyes?
Yes
No
Been a metal worker?
Yes
No
Had an MRI scan in the past?
Yes
No
Do you have (or have you ever had) any of the following?
Yes
No
1. Pacemaker
Yes
No
2. Pacing wires/ defibrillator
Yes
No
3. Brain aneurysm clip
Yes
No
4. Cochlear implant
Yes
No
5. Artificial heart valve repair/ replacement
Yes
No
6. Neurostimulator/ Biostimulator
Yes
No
7. Brain shunt tube
Yes
No
8. Any intravascular coils, filters or stents
Yes
No
9. Metal pin, plates, rods or screws
Yes
No
10. Dentures, dental implants or braces
Yes
No
Yes
No
11. Shrapnel or bullet wounds
Yes
No
12. Implanted pain relief pump
Yes
No
13. Implanted insulin pump and/ or wearable glucose sensors
Yes
No
14. Any other form of implant
Yes
No
15. Hearing aid
Yes
No
16. Transdermal (Skin) patches e.g nicotine patches
Yes
No
17. Wig, hairpiece, hair extensions
Yes
No
18. A tattoo or body piercing
Yes
No
19. Do you understand all these questions
Yes
No
I acknowledge that to the best of my understanding, the above answers are true and correct:
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STAFF Only: Safety Checklist verbally confirmed by MRI Technologist : Yes No
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Signature of MRI technologist
Did you need an interpreter to answer the above form?
Yes
No
Private Patients or Pensioners: The costs involved with this procedure have been clearly explained and I accept responsibility for these changes
Interpreter's Consent: I have provided a sight translation of the patient consent form. I also have assisted the patient /paremt and/or guardian with any verbal and written information given by the medical imaging professionals
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Abdo Pelvis Questionnaire
MRI Tech
Why are you having this MRI today?
How long have you had your symptoms for?
Does anything aggravate the symptoms? (Eg. eating, fatty foods, physical activity)
Do you have a history of cancer?
Yes
No
if Yes, what type & what year were you diagnosed?
What type of treatment?
Yes
No
Radiation Therapy
Yes
No
Chemotherapy
Yes
No
Surgery
Yes
No
Have you had any previous surgery? If yes, please list surgery type and date:
Females Only: Are you currently taking the pill or HRT?
Yes
No
Females Only: when was you last menstrual period?
Males Only: Do you now your current PSA: if yes, PSA level and date?
Please let us know of any previous imaging of this area
MRI
CT Scan
Ultrasound
Nuclear Medecine (eg PET)
ERCP/ Endoscopy
Other
When and Where was the imaging done?
Are you experiencing pain ?
Yes
No
Please accurately shade the diagram to show the exact site of your pain
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