MRI Safety Questionnaire and Instructions for MRI/MRV/MRCP & MR Arthrogram "*" indicates required fields 12/05/2024Name* First Last Email* DOB* MM slash DD slash YYYY MRN#* Weight Height Date of Injury or Accident MM slash DD slash YYYY Is this work related?* Yes No Please provide a “yes” or “no” answer for every item.Cardiac pacemaker/defibrillator/ICD* Yes No Aneurysm clip(s)/metal stent* Yes No Internal electrodes or wire* Yes No Bone growth stimulator, DBS, VNS* Yes No Magnetic implant or IVC Filter* Yes No External drug pump* Yes No Spinal fusion and/or halo vest* Yes No Any chance you are pregnant* Yes No Ear implant, middle ear implant* Yes No Medication patch* Yes No Implanted drug pump/insulin pump* Yes No Wigs, hair implants* Yes No Tissue expander (breast)* Yes No Hearing Aid(s)* Yes No Eye injury from a metal object* Yes No Ankle monitor* Yes No Injured by metal (shrapnel,bullet)* Yes No Artificial eye and/or eyelid spring* Yes No Neurostimulator or Biostimulator* Yes No Shunt/Sophy pressure valve* Yes No Spinal fixation device or stimulator* Yes No Any metal inside or outside of body* Yes No Instruction for the Patient, Parent or Guardian: 1. Remove all jewelry and all body piercing jewelry and all hair accessories. 2. Remove all dentures, partial dental plates, retainers (for brain, head or neck examinations). 3. Remove hearing aids and eyeglasses and bobbie pins. 4. Remove wallet and anything in your pockets. 5. Remove wigs ( for brain, head or neck examinations). 6. Lock your clothes and valuables in the locker or room provided and remove the key.* I attest the above information is correct to the best of my knowledge. I have read and understand the entire contents of this form and I have had the opportunity to ask questions regarding the information on this form.