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MRI Screening Questions Form

WE CANNOT SCHEDULE YOUR MRI WITHOUT THE BELOW INFORMATION.
PLEASE COMPLETE AT YOUR SOONEST CONVENIENCE.
Radiology MRI Screening - TMallon
Name
Name
No menstruation cycles
Do you have a pacemaker, pacing wires, defribrillator?
Do you have any implanted devices in your head or body (including sleep apnea device/stimulator)?
Do you have any implanted shunts or stents?
Have you had any ear or eye surgeries?
Do you have any piercings that would need to be professionally removed?
Do you wear a transdermal medication patch?
Do you have any aneurysm clips or coils?
Within the last 3 months have you ingested a pill camera or bowel capsule?
Have you ever had an injury to your eye(s) involving metal such as from wielding/grinding?
Do you have any metallic objects lodged in your body such as bullets, BBs, or shrapnel?
Do you use a continuous glucose monitor system such as Dexcom, Freestyle, or Libre?
Have you had a Colonoscopy, Endoscopy, or Sigmoidoscopy in the last 3 months?
Have you had any surgeries in the last 2 months?
Have you had any surgeries on the area being scanned?
Have you had any prior imaging of the area being scanned (neuro) at another imaging facility?
Do you have a pessary ring (for bladder support)?
Do you have a wearable medication injector?
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