CLMRAD MRI Questionnaire

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Occupation *

Weight (kgs) *

Do you have or have you had any cardiac implants? *

Cardiac pacemakerPacing wiresDefibrillatorLoop recorderArtificial heart valveNo cardiac devices

Do you have any intravascular stents, coils or filters? *

YesNo

Please specify the intravascular stents, coils or filters *

Do you have any of the following ear or mouth devices? *

Ear implantsCochlear implantsHearing AidDenturesBracesNo ear or mouth devices

Have you had any head, eye, ear, heart or spinal surgery? *

YesNo

Please specify what head, eye, ear, heart or spinal surgery you have had *

Do you have metal fragments in your eyes (now or ever, i.e. welding, grinding)? *

YesNo

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

YesNo

Please describe injury by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.) *

Do you have any metal implants/devices e.g. neurostimulator, bone stimulator or drug infusion pump? *

YesNo

Please specify metal implant/device e.g. neurostimulator, bone stimulator or drug infusion pump *

Aside from what you have already mentioned in the questions above, do you have any other devices inserted in your body? *

YesNo

Please specify any other devices *

Do you have any body piercing, patches, permanent makeup or tattoos? *

Body piercingPatches (ie. pain, hormone/nicotine)Permanent makeupTattoosNo body piercing, patches, permanent makeup or tattoos

Have you had any surgery in the last 12 months? *

YesNo

Please specify surgery in the last 12 months? *

Have you had a colonoscopy, gastroscopy or endoscopy in last 6 weeks? *

ColonoscopyGastroscopyEndoscopyNo colonoscopy, gastroscopy or endoscopy in last 6 weeks

Are you currently on dialysis or do you have any renal/kidney problems? *

YesNo

Please tell us your eGFR (kidney fuction) from your latest blood test if you know the details *

Are you or could you be pregnant? *

YesNoMaybe/unsure

Are you breastfeeding? *

YesNo

Are you having a Breast MRI? *

YesNo

Please tell us the date of last menstrual cycle. *

Have you been given oral sedatives by your requesting Doctor?

YesNo

Do you have any allergies? *

YesNo

Please specify your allergies *

Are you claustrophobic? *

YesNo

Are you able to walk a few metres without assistance (eg cane/walker/wheelchair etc)? *

YesNo

If you are are unable walk without assistance, please provide details below. *

A MRI injection may be required for your examination. Do you give consent to an intravenous gadolinium contrast injection? *

YesNo

I confirm that I have answered the above questions and that the information is true and correct.

Patient/Guardian Signature *

Draw signature|Type signatureClear

Today's date *

Do not enter the scan room with a watch, wallet/purse, credit/teller cards, or loose metal objects (e.g. keys) as DAMAGE CAN OCCUR TO THESE ITEMS.

Please indicate the area of your injury or pain for the region being scanned on the diagram below.

Clear drawing

Have you injured the area being scanned?

Describe your symptoms or pain:

How long have you had the symptoms or pain?

Have you had any surgery on the region being scanned? If yes please specify:

For security please complete the check below *

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