It is important that you answer all of the following questions. 9 Yes 9 No 7. MRI Safety Screening Questionnaire MRI, unlike other methods of imaging the body, does not use radiation but rather uses magnetism and radio waves. 6. The screening form will open up. Below that is the screening … i also understand the above questions and … Are you pregnant or possibly pregnant? When an MRI is ordered, a task will appear on the worklist to complete the MRI Screening Form. MAGNETIC RESONANCE IMAGING (MRI) QUESTIONNAIRE. A standard hospital approved MRI screening form is to be filled out prior to a patient entering Zone 3/4. Extensive evaluation has shown no long … 9 Yes 9 No 8. MRI SCREENING QUESTIONNAIRE 17163 0907 ESI# 138233 *17163* ˜˚˜˛˝ Community Hospitals of Indiana, Inc. ˜ Community Hospital East ˜ Community Hospital North ˜ Community Hospital South ˜ Community Imaging Center OUTPATIENT MRI QUESTIONNAIRE … Form # 819 Created 5/2020 . vdrive/forms/mri/mri patientscreeningform/updated 8/9/2019 mri screening form name: _____ d.o.b:___/___/___ age: ____ sex: m / f The introduction of certain metallic objects into the magnet area also has ... MRI Screening Questionnaire … MRI Screening Questionnaire MRN #: MRN# DOB: Patient Name: Date: Provider: 2 . MR Safety continues to evolve and in response, the ACR's Committee on MR safety created the ACR Manual on MR Safety with updates and critical new information which replaces all earlier … mri patient screening questionnaire and consent form . MRI Worker Screening Form ... An MRI instrument produces a strong magnetic field that is ALWAYS ON. 2. This questionnaire is designed to assist us in determining if it is safe for you to undergo a magnetic resonance imaging procedure. Are you allergic to any … cardioverter defibrillator (ICD) Electric device or implant YES NO … CBI MRI Screen Version 050120 MRI Metal Screening Questionnaire Must be completed on the day of the scan Sub ID/Name: _____ Age _____ Height _____ Weight _____ Instructions: The following items may be harmful in the scanner or may interfere with the MRI … Are you breastfeeding? MRI PATIENT SCREENING QUESTIONNAIRE If you answered YES to any of the questions on the front page, please discuss any concerns and/or issues you may have, with your MR … If you don’t understand any question, ... MRI Screening Questionnaire … There is some general information about the patient and the MRI that was ordered at the top left portion of the page. It will be the responsibility of the MRI technologist to review the MRI screening … This strong magnetic field has the potential to harm individuals with certain medical implants and/or conditions. surname first name date of birth chi height weight ... i understand the mri examination. When ready to complete the form, click . Patient Screening Patients entering an MRI suite for a diagnostic exam are screened for the contraindications discussed above. Side 2 of 2.