MRI Screening Form
Yes No
1. Do you have a cardiac pacemaker or cardiac defibrillator?
2. Do you have an aneurysm clip? Aneurysm repair?
3. Do you have an artificial cardiac heart valve?
4. Do you have any mechanical devices, pumps, stents, implants
(neurostimulators, cochlear, etc.)?
If yes, please list all currently implanted devices and dates.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5. Have you ever had a surgical procedure or operation of any kind?
If yes, please list all prior surgeries and approximate dates:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. Have you ever had an eye injury involving metal? Any history of any
grinding/welding? (e.g., metallic slivers, shavings,foreign body, etc.)?
If yes, please describe:
__________________________________________________________________
7. Have you ever been injured by a metallic foreign body (e.g., bullet, BB,
shrapnel, etc.)?
If yes, please describe:
__________________________________________________________________
8. Are you pregnant or do you suspect that you are pregnant?
I, the undersigned student, have answered the above questions accurately. This is imperative
for my personal safety and the safety of my patients. I know prior to entering the MRI area, I
must remove all hearing aids, jewelry, credit cards, eyeglasses, pins and electronic devices.
The Magnetic Field is ALWAYS ON
Additional Notes:
_______________________________ ________________________________
Print Student Name Print Staff Name Date
_______________________________ ________________________________
Student Signature Date Staff Signature – reviewed form and witnessed Student Signature
Vance Granville Community College --- Student MRI Screening Form
A student must complete this form before rotating through MRI
