University Radiology | NJ Imaging Center & Diagnostic Radiology

Patient Name

Date of Exam

Date of Birth

Sex:

M F

Have you had prior surgery or an operation (e.g. arthroscopy, endoscopy, etc.) of any kind?

Yes No

Have you experienced any problem related to a previous MRI examination or MR procedure?

Yes No

Have you had an injury to the eye involving a metallic object or fragment (e.g. metallic slivers, shavings, foreign body, etc.)?

Yes No

Has any other body part had a penetrating injury by a metallic object or foreign body (e.g. bullet, BB, shrapnel, etc.)?

Yes No

Have you had a colonoscopy or upper endoscopy ("EGD") within the past 3 months?

Yes No

Please indicate if you have any of the following:

Aneurysm clip(s)

Yes No

Pacemaker or defibrillator (ICD)

Yes No

Any metallic fragment or foreign body

Yes No

Electronic implant or device

Yes No

Joint replacement (hip, knee, etc.)

Yes No

Neurostimulator device

Yes No

Internal electrodes or wires

Yes No

Bone growth / bone fusion stimulator

Yes No

Cochlear, otologic, or other ear implant

Yes No

Implanted drug infusion (e.g. insulin, pain meds)

Yes No

Any type of prosthesis (eye, penile, etc.)

Yes No

Heart valve prosthesis

Yes No

Eyelid spring or wire

Yes No

Artificial or prosthetic limb

Yes No

Metallic stent, filter, or coil

Yes No

Shunt (spinal or intraventricular)

Yes No

Vascular access port and/or catheter

Yes No

Radiation seeds or implants

Yes No

Swan-Ganz or thermodilution catheter

Yes No

Medication patch (nicotine, nitroglycerine, etc.)

Yes No

Wire mesh implant

Yes No

Tissue expander (e.g. breast)

Yes No

Surgical staples, clips, or metallic sutures

Yes No

Bone / joint pin, screw, nail, wire, plate, etc.

Yes No

IUD, diaphragm, or pessary

Yes No

Dentures or partial plates

Yes No

Tattoo or permanent makeup

Yes No

Body piercing jewelry

Yes No

Hearing aid

Yes No

Breathing problem or motion disorder

Yes No

Claustrophobia

Yes No

Other Implant

Yes No

MRI Questionnaire

Please indicate if you have any of the following: