Scribd
Upload
44 views1 page

MRI Saftey Questionnaire MMUH

The document is a Patient Safety Questionnaire and MRI Consent Form that ensures patients disclose any metal in their bodies before undergoing an MRI scan. It includes a series of yes/no questions regarding medical history and potential risks associated with the MRI procedure. Patients must sign the form to confirm their understanding and agreement to proceed with the imaging.

Uploaded by

rajaahamed786
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
44 views1 page

MRI Saftey Questionnaire MMUH

The document is a Patient Safety Questionnaire and MRI Consent Form that ensures patients disclose any metal in their bodies before undergoing an MRI scan. It includes a series of yes/no questions regarding medical history and potential risks associated with the MRI procedure. Patients must sign the form to confirm their understanding and agreement to proceed with the imaging.

Uploaded by

rajaahamed786
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PATIENT SAFETY QUESTIONNAIRE AND MRI CONSENT FORM

Magnetic Resonance Imaging is a way of looking inside the body using radio waves, a large
magnet and a computer. There are no X-rays involved. As this is a very large magnet, it is
very important that you complete this questionnaire carefully. This will let the Radiographer
know of any metal on or in your body, which may be a danger to you, or someone else, when
entering the scanning room.

PLEASE ANSWER THE FOLLOWING QUESTIONS YES NO


Q1: Do you have a cardiac pacemaker or surgery on your heart?
Q2: Have you ever had any surgery to your head or back?
Q3: Do you have any eye, ear or breast implants?
Q4: Have you had any metal fragments in your eyes, or have you
ever worked with metal?
Q5: Do you have, or have you had any metal fragments in any
other part of your body, e.g. shrapnel, bullet, belly-ring etc?
Q6: Could you be claustrophobic?
Q7: Do you suffer with epilepsy?
Q8: Do you suffer with diabetes or renal dysfunction?
Q9: Do you suffer from any allergies?
Q10: Could you be pregnant or are you breast -feeding?
Q11: Have you had a previous MRI scan?

Please tick which of the following items apply to you :

Aortic or vascular or aneurysm clips Implanted drug pump


Artificial heart valve Neurostimulators
Artificial eye or limb Permanent cosmetic eye lining or tattoos
Bone or joint replacement Penile Implant
Metal rods, plates or pins Wire mesh, wire sutures or staples
Dentures or partial plates Implanted cardiac defibrillator
Carotid clips Any type of coil, filter or stent
Cochlear or ear Implants Eyelid spring
Electronic monitoring device Medication patch
Harrington rods IV access port
Hearing aids Shunt
Body Piercing Other implanted item in body

I have read, understood and completed to the best of my knowledge, the questions on this consent
form and agree to be imaged.

Patient Signature________________________________ Weight (kg) _________ Date _________

Radiographer ______________________________

You might also like