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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Ankle & Foot Questionnaire
MRI Tech
Region of Scan
Left Ankle / Foot
Right Ankle / Foot
1. Describe your symptoms:
What were your symptoms caused by ?
Single specific Injury
Repetitive Injury
Not Injury related
Not applicable
When did this first occur?
Please describe your injury
Have you ever fractured or dislocated this joint?
Yes
No
Has your range of movement decreased?
Yes
No
Are you able to bear weight on your leg?
Yes
No
Have you ever had a ankle/foot Injection?
Yes
No
What Injection?
Cortisone
Other
Did it help?
Yes
No
Have you ever had a ankle/foot surgery?
Yes
No
Have you had a ankle arthroscopy?
Yes
No
When
Name of Surgeon
Have you had any previous diagnostic performed on your ankle / foot?
X-ray
CT
MRI
Ultrasound
Bone Scan
When and Where was your previous imaging done?
MRI Tech use only
Int: on PACS
Ext: Available
Ext: Report Scanned
Ext: N/A
Please accurately shade the diagram to show the exact site of your problem (please hold your phone horizontal to do this)
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