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Monroeville Patient Screening Form

Please fill out this form before your visit.

Date of Birth
Sex
Male
Female

Please check Yes or No to all of the following:

Claustrophobia
Yes
No
Heart Condition
Yes
No
High Blood Pressure
Yes
No
Anemia (or other blood condition).
Yes
No
Diabetes
Yes
No
Seizures
Yes
No
Pregnant
Yes
No
Cancer
Yes
No

Please select either Yes or No if you have any of the following:

These will not prevent you from having an MRI procedure, but it is important for us to know this information.

Any type of surgical clip or staple?
Yes
No
Any IV access port (e.g. Hiekman, Port-o-Cath)?
Yes
No
Shunt
Yes
No
Artificial Eye
Yes
No
Have you had a Spinal Fusion procedure?
Yes
No
Have you had a Spinal Fusion device?
Yes
No
Do you have an artificial limb?
Yes
No
Have you ever had a reaction with Contrast?
Yes
No
Pacemaker
Yes
No
Neurostimulator or Vagel Stimulator
Yes
No
Prosthetic Device
Yes
No
Heart valve of stent(s)
Yes
No
Inferior Vena Cava FIlter
Yes
No
Shrapnel or bullets
Yes
No
Hearing Aids/Cochlear Implant(s)
Yes
No
Dentures
Yes
No
Metal Implants
Yes
No
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