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 /parent and/or guardian with any verbal and written information given by the medical imaging professionals
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MRI Head / Brain/ TMJ Questionnaire
MRI Tech..........................
Do you experience any of the below symptoms:
Yes
No
Headaches
Yes
No
Dizziness or Imbalance
Yes
No
Loss of hearing
Yes
No
Tinnitus/ ringing in the ears
Yes
No
Loss of vision/ blurred vision
Yes
No
Numbness or Tingling in limbs
Yes
No
Episodes of fits of Seizures
Yes
No
Family history of strokes
Yes
No
Do you have a history of :
Yes
No
Any trauma to the head area
Yes
No
Family history of aneurysm
Yes
No
Migraines
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Diabetes
Yes
No
Cancer
Yes
No
Vasculitis
Yes
No
Are you on blood thinners?
Yes
No
Do you smoke?
Yes
No
Any previous Imaging?
MRI
CT
X-RAY
MRI Tech use only
(Please Circle)
Int: On PACS Ext: Available on PACS Ext: Report only Ext: N/A
When and where was any previous imaging performed?
Please accurately shade the diagram to show the exact site of your pain
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