CMI Safety Questionnaire

Name

First Name

Last Name

Date of Birth

Date

Gender* This field is required.

Female

Male

Have you had surgery or an operation?* This field is required.

Yes

Unknown

Please list date of surgery and type:* This field is required.

Have you had any surgical procedures in the last 6 weeks?* This field is required.

Yes

What type of surgery or procedure?* This field is required.

Do you have a problem with the ability of staying still or are you claustrophobic?* This field is required.

Yes

Unknown

Are you taking any medications for claustrophobia or do you prefer an Open MRI?* This field is required.

I do not require a medication or Open MRI.

I am taking a medication for claustrophia perscribed by my medical provider.

I would prefer an Open MRI.

Have you ever worked with metal?* This field is required.

Yes

Have you had an injury to the eye involving a metallic object (e.g., metallic slivers, foreign body)?* This field is required.

Yes

Unknown

Describe injury to eye and were you evaluated by an MD?* This field is required.

Are you currently wearing Magnetic Eye Lashes?* This field is required.

Yes

Please removed magnetic eyelashes prior to your appointment.

Do you have any food or medication allergies?* This field is required.

Yes

Unknown

If yes, please list allergy and type of reaction.* This field is required.

Have you ever had a reaction to CT or MRI contrast?* This field is required.

Yes

What type of reaction and to what contrast medium?* This field is required.

Are you currently undergoing dialysis treatment?* This field is required.

Yes

If yes, how often do you go and what facility does your treatments?* This field is required.

Are you on any Blood or Body Fluid Precautions or Infection Control Precautions?* This field is required.

None

Hepatitis

Shingles

MRSA

VRE

COVID-19 Quarantine

Are you pregnant or suspect that you are pregnant?* This field is required.

Yes

Unknown

Please indicate Trimester?* This field is required.

First Trimester

Second Trimester

Third Trimester

Are you currently Breastfeeding?* This field is required.

Yes

The American Academy of Radiology recommends that you express and discard your breast milk for 24 hours post MRI procedure, if you are receiving MRI contrast.

Have you ever had a detached retina?* This field is required.

Yes

Unknown

What type of retinal repair did you have and who was the surgeon?* This field is required.

Have you traveled outside the U.S. in the last 21 days?* This field is required.

Yes

If yes, please describe:* This field is required.

Are you being treated for or have a history of any of the following diseases? You may pick more than one.* This field is required.

High Blood Pressure

Diabetes

Kidney Disease

Liver Disease

None of the above

Have you had or are you scheduled for a liver transplant?* This field is required.

Yes

Unknown

Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)?* This field is required.

Yes

Unknown

Please describe injury?* This field is required.

Do you have body piercings or body jewelry* This field is required.

Yes

If yes, what type?

Are you wearing any clothing with metal such as copper or silver?* This field is required.

Yes

Remove all metallic objects before entering the MR environment or MR system room including hearing aids, beeper, cell phone, keys, eyeglasses, hair pins, barrettes, jewelry (including body piercing jewelry), watch, safety pins, paperclips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, steel-toed boots/shoes, and tools. Loose metallic objects are especially prohibited in the MR system room and MR environment.
Please consult the MRI Technologist or Radiologist if you have any question or concern BEFORE you enter the MR system room.

Do you have a Cardiac Pacemaker or Defibrillator?* This field is required.

Yes

Unknown

Do you have a loop recorder?* This field is required.

Yes

Unknown

Who is your Cardiologist?

Do you have aneurysm clips or coil?* This field is required.

Yes

Unknown

Why type and where/when was the surgery?* This field is required.

Do you have any of the following (all the apply)?* This field is required.

Heart Valve Prosthesis

Stents or Filter

Shunts

Internal Electrodes or Wires

Vascular Access Port and/or Catheter

Ear Implant or Hearing Aid

Radiation Seeds or Implants

History of Seizures

Shrapnel, Bullet Fragments or Metal in your body

Any type of Implant

Any type of Prosthesis

Any Artificial Limbs or Joint Replacements

Surgical Staples, Clips or Sutures

Bone/Joint Pins, Plates, Nails or Screws

Insulin, Infusion Pumps or Sensors

Bone Growth or Fusion Stimulators

Neurostimulator

Dentures, Braces or Removable Dental Items

Medication/Skin Patch (nitro, nicoderm, ortho etc...)

IUD, Pessary or Diaphragm

Asthma or Respiratory Disease

Tattos or Tattooed Makeup

None of the above

Please describe if you checked an item above:

WARNING: Certain implants, devices, or objects may be hazardous to you in the MR environment or MR system room. Do not enter the MR environment or MR system room if you have any question or concern regarding an implant, device, or object.

Remove all metallic objects before entering the MR environment or MR system room including hearing aids, beeper, cell phone, keys, eyeglasses, hair pins, barrettes, jewelry (including body piercing jewelry), watch, safety pins, paperclips, money clip, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, steel-toed boots/shoes, and tools. Loose metallic objects are especially prohibited in the MR system room and MR environment.
Please consult the MRI Technologist or Radiologist if you have any question or concern BEFORE you enter the MR system room.

I attest that the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and have had the opportunity to ask questions regarding the information on this form.

Current Weight:* This field is required.

Signature of person completing form:

Clear

Relationship to patient.* This field is required.