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MR Patient Checklist
Name:__________________________________________
The Following Items May Be Hazardous or May Interfere with the MRI
Examination by Producing an Artifact.
Please indicate if the patient has the following:
| Contraindications |
YES |
NO |
| • Cardiac pacemaker | | |
| • Aneurysm clip(s) in the brain | | |
| • Implanted cardiac defibrillator | | |
| • Any type of biostimulator/neurostimulator | | |
• Any type of electronic, mechanical or magnetic implant
Type: ____________________________________ | | |
| • Implanted drug infusion device | | |
| • Implanted insulin pump | | |
| • Any type of metallic foreign body, shrapnel or bullet | | |
| • Any metal shavings in orbital area (machinist or metal worker) | | |
• Any type of intravascular coil, filter or stent
(Gunther IVC filter) Date:__________ | | |
| • Any type of internal electrode(s), including Pacer wires | | |
| • Cochlear implants (ear implants) | | |
| • Orbital eye prosthesis (eye implant) | | |
| • Holter Monitor | | |
| Additional Information |
YES |
NO |
| • Heart valve prosthesis
Type:___________________________ | | |
| • Halo vest or metallic cervical fixation device | | |
| • Any type of surgical clip or staple(s) | | |
| • Vascular access port | | |
| • Intraventricular shunt | | |
• Any implanted orthopedic item(s) (i.e., pins, rods, screws, nails, clips,
plates, wire etc.)
Type: ____________________________________ Location:__________________________________ | | |
| • Pessary | | |
| • IUD/Diaphragm | | |
| • Artificial limb or joint | | |
| • Permanent eye liner | | |
| • Hearing Aid | | |
| • Does patient weight 300 pounds or more? | | |
| • If female patient, is she pregnant?
LMP:__________________ | | |
| Medication/Sedation |
YES |
NO |
| • Is patient able to cooperate ? (must be able to lie still for approx. 1
hour) | | |
| • Is pain medication required for patient cooperation? | | |
| • Is sedation required for claustrophobia? | | |
Print Patient's Name:__________________________________________
Patient or Family Member Signature:______________________________
Relationship:________________________________________________
Recept/RT Signature:_________________________________________
Revised 10/97
Copyright © 2008
Parkside Magnetic Resonance Center
http://www.parksidemri.com
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