The MR system has a very strong magnetic field that may be hazardous to individuals entering the
MR environment or MR system room if they have certain metallic, electronic, magnetic, or mechanical
implants, devices, or objects. Therefore, all
individuals are required to fill out this form BEFORE entering
the MR environment or MR system room. Be advised, the MR system magnet is ALWAYS on.
MAGNETIC R ESONANCE (MR) ENVIRONMENT SCREENING FORM FOR I NDIVIDUALS*
*NOTE: If you are a patient preparing to undergo an MR examination, you are required to fill out a different form.
Date _____/_____/_____ Name ____________________________________________________ Age _______
month day year Last Name First Name Middle Initial
Address __________________________________________ Telephone (home) (_____) _____-________
City __________________________________________ Telephone (work) (_____) _____-________
State ____________________ Zip Code ___________
1. Have you had prior surgery or an operation (e.g., arthroscopy, endoscopy, etc.) of any kind? No Yes
If yes, please indicate date and type of surgery: Date ____/____/____ Type of surgery________________
2. Have you had an injury to the eye
involving a metallic object (e.g., metallic slivers, foreign body)? No Yes
If yes, please describe: _____________________________________________________________________
3. Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)? No Yes
If yes, please describe: _____________________________________________________________________
4. Are you pregnant or suspect that you are pregnant? No Yes
Please indicate if you have any of the following:
Yes No Aneurysm clip(s)
Yes No Cardiac pacemaker
Yes No Implanted cardioverter defibrillator (ICD)
Yes No Electronic implant or device
Yes No Magnetically-activated implant or device
Yes No Neurostimulation system
Yes N
o Spinal cord stimulator
Yes No Cochlear implant or implanted hearing aid
Yes No Insulin or infusion pump
Yes No Implanted drug infusion device
Yes No Any type of prosthesis or implant
Yes No Artificial or prosthetic limb
Yes No Any metallic fragment or foreign body
Yes No Any external or internal metallic object
Yes No Hearing a
id
Yes No Other implant______________________
Yes No Other device______________________
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. If any of the information you provide on this screening form should change prior to or
during enrollment in the ECC MRI program, you must notify the MRI Clinical Coordinator or Program Director immediately to be screened again to ensure
you are able to enter in and work in the MR environment.
In the event you fail to notify or report changes to this information, you release Elgin Community
College and the faculty of all legal responsibility for any injury that occurs as a result.
Initials _______.
Signature of Person Completing Form:
______________________________________
Date _____/_____/_____
Signature
Form Information Reviewed By: _____________________________________ ______________________________________
Print name Signature
Radiologist ______________________________
IMPORTANT INSTRUCTIONS
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.
MRI Technologist Other
