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MRI Screening Questions Form

WE CANNOT SCHEDULE YOUR MRI WITHOUT THE BELOW INFORMATION.
PLEASE COMPLETE AT YOUR SOONEST CONVENIENCE.

"*" indicates required fields

Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
No menstruation cycles
Do you have a pacemaker, pacing wires, defribrillator?*
Do you have any implanted devices in your head or body?*
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) involiving metal such as from weilding/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 past 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?*
This field is for validation purposes and should be left unchanged.
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