Can anyone have an MRI?
The following questions will help you determine if you can have an MRI:
Height ft. in.
Weight lbs.
Y
N
1.
 Is the scan ordered the result of an auto accident or work related injury?
2.
 Have you ever had surgery on the area we will be scanning?
3.
 Have you had a heart valve replacement?
4.
 Have you had a surgical repair for an aneurysm
5.
 Do you have a blood clot filter?
6.
 Any objects surgically implanted anywhere in your body including eye lens or middle ear implants?
7.
  Have you ever had metal washed or removed from your eyes?
8.
 Have you ever done any metal welding grinding or drilling as an occupation?
9.
  Are you pregnant or nursing?
10.
  Do you have any internal contraceptive device?
11.
 Do you have an insulin pump, metaport or permanent catheter?
12.
Are you claustrophobic?
13.
Do you personally have a history of cancer?
14.
Have you ever had open heart surgery?
15.
Have you ever had any kind of brain surgery?
16.
Do you have any permanent eye liner or tattoos?
17.
 Do you have tissue expanders or transdermal patches?
18. Are you on dialysis or have any kidney function problems?
19. Are you diabetic?
 
 
 
 
 
 
 
 
 

If you would like to print this form, click here
Although there is no special patient preparation, a patient is screened for metallic objects that may interfere with the test and may have to have x-rays to verify these objects are not present.

The following is a list of the most commonly screened devices for MRI:

• Surgically repaired heart valves
• Metal fragments, such as shrapnel
• Implanted pumps, such as insulin and chemotherapy
• Cochlear implants or stapes implants

MRI scans are not performed on patients with:

• Pacemakers
• Surgical Aneurysm clips in the brain
• ACLS Equipment, such as a lifepak or respirator
Contact us as at 1-800-233-0272