fMRI Screening Form

MRI Subject Safety Screen

Please complete prior to MR examination.

Last Name:				First Name:
Date of Birth:		Height:		Weight:	lbs.

Check one: Outpatient Research Volunteer

The following items may be hazardous to your health, or may interfere with the MRI study by producing artifacts.
	Are you a metal worker or have you worked with metal lathes?	If yes, have you always worn eye protection?
Please check if you may have any of the following:
	Metal fragments in your eyes
	Cardiac Pacemaker	Aneurysm clip
	Any type of internal electrode(s) Pacing wires, Cochlear Implant, etc...	Implanted Insulin Pump
	Swan-Ganz Catheter	Halo vest or metallic cervical fixation device
	Hearing Aid	Any type of intravascular coil, filter or stent
	Implanted Drug Injection Device	Any type of foreign body, shrapnel or bullet
	Heart Valve Prosthesis	Any type of Ear Implant
	Penile Prosthesis	Any type of surgical clip or staple
	Vascular Access Port	Intraventricular Shunt
	Artificial Limb or Joint	Dentures
	Diaphragm (in place)	IUD
	Tattooed eyeliner	Wire Mesh
	Any type of electronic, mechanical or magnetic implant	Any type of implant held in place by a magnet
	Any implanted orthopedic items (e.g. pins, rods, screws, nails, clips, plates, wire, etc...)	Implanted cardiac defibrillator
	Neurostimulator
	Any type of biostimulator. Describe:	Any other implanted item. Describe:

Female Subjects, please complete the following:
Are you pregnant, or do you suspect that you are pregnant?:	Yes No
Are you Breast Feeding?:	Yes No
Are you taking oral contraceptives, or receiving hormone treatment?:	Yes No

Have you ever had a surgical procedure of any kind?: Yes No
If yes, please list all prior surgeries and approximate dates (or Unknown):

Have you ever been injured by any metallic foreign body?
(e.g. bullet, BB, shrapnel, etc...): Yes No
If yes, please describe:

Have you ever had an injury to the eyes involving a metal object?
(e.g. metallic slivers, shavings, foreign body, etc...): Yes No
If yes, please describe:

Have you experienced any problem related to a previous MRI procedure?
(e.g. allergic reaction to contrast, claustrophobia ) Yes No
If yes, please describe:

Have you had any other imaging for this problem?
(e.g. CT,MRI,PET,Nuclear Medicine,xray ) Yes No
If yes, please describe:

Before entering the MR environment you MUST remove all metallic objects including hearing aids,dentures,partial plates,keys,beepers,cellphones,eyeglasses,hair pins,safety pins,paperclips,money clip, credit cards, magnetic strip cards, coins,pens,pocket knife,scissors,nail clipper,tools,clothing with metal fasteners or zippers and clothing with metallic threads. Do you have any other questions?
Please. make sure you ask the technologist Yes No
If yes, please describe:

Referring doctor:

Š2006 Philip W. Chao