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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MRI Spine Questionnaire
MRI Tech
Region:
C/Spine
T/Spine
L/Spine
SI Joints
Sacrum
Coccyx
Was it caused by:
Single injury
Repetitive Injury
Unsure
Accurately shade the diagram to show the exact site of your symptoms:
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Please describe your symptoms (with details of the injury if applicable)
Do you experience any of the following?:
Numbness
Tingling
Weakness
When did this occur?
Are you experiencing symptoms down your:
Left Arm
Right Arm
Left Leg
Right Leg
Symptoms worse on the:
Left
right
Does anything make your symptoms better?
Does anything make your symptoms worse?
Have you ever had a Spine Injection?
Yes
No
What Injection & When did you have it
Did it help?
Yes
No
Have you ever had any Surgery to the area of interest
Yes
No
When / What Surgery? Who was the Surgeon?
Do you have any bowel or bladder changes?
Yes
No
Have you had any previous imaging on your spine?
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
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