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MRI safety

MRI safety

MRI Safety Questionnaire

The importance of the MRI Safety Questionnaire

Your safety is our highest priority. The MRI Safety Questionnaire is a vital part of our screening process.

It allows us to:

identify any implants or devices that may affect your scan
determine the safest scanning protocol tailored to your needs
prevent potential complications during the examination

Completing the questionnaire accurately ensures we can provide you the safest and most effective imaging experience.

Patient details

First name *

Last name *

Date of birth *

Date *

Email

Phone *

Please list the number we can most easily contact you on

Height (cm) *

Weight (kg) *

Booking details

Do you have an MRI appointment booked with us? *

Yes

No

Branch where your MRI appointment is booked

Branch email

Appointment date

Date

Patient history

Have you had a previous MRI, or any related imaging related to this scan? *

Yes

No

Please provide details of when and where *

Have you had surgery or another procedure in the past 6 weeks? *

Yes

No

Please provide us with as much relevant detail about that surgery: *

eg. type of procedure, when, where performed, name of surgeon

Is there anything you would like the MRI staff to know to help make your scan more comfortable? *

(e.g., sensory or neurodivergent conditions, mobility needs etc)

Yes

No

Please provide us with as much relevant detail about that condition: *

Surgically implanted medical devices

Do you have or have you had any of the below medical devices implanted?

Cardiac pacemaker, defibrillator or pacing wires (excluding stents, bypass and heart valves) *

Yes

No

Implanted cardiac monitoring device such as a loop recorder *

Yes

No

Any heart surgery *

Yes

No

Was anything implanted? *

Electrical stimulator for nerves, brain or bone *

Yes

No

Implanted or external infusion or drug pump *

Yes

No

Shunt (programmable, VP or spinal shunt) *

Yes

No

Coils or filters *

Yes

No

An aneurysm clip *

Yes

No

Stents anywhere in the body *

Yes

No

Where in the body are they implanted?

Eye or ear surgery (e.g. cochlear or stapes. Excluding cataracts) *

Yes

No

Was there any implants inserted?

A gastric band *

Yes

No

What year was it implanted?

Genital or reproductive implants *

Yes

No

Do you have a breast tissue expander implanted? *

Yes

No

Any other surgically implanted devices (excluding joint replacements, orthopaedic implants and dental implants) *

Yes

No

What was implanted?

Other considerations

In order for Benson Radiology to best manage your MRI, please answer the below. The following may impact image quality or if removable, may be asked to be removed prior to entering the MRI room.

Do you have any of the below?

Tattoos or permanent make up *

Yes

No

Removable dental work, dentures or dental plates *

Yes

No

Hearing aids *

Yes

No

Medicated or metallic backed patches or dressings *

Yes

No

Continuous Glucose Monitor (CGM) or alternative monitoring device?

Yes

No

Have you ever had an eye injury caused by metal? *

Yes

No

Was it seen to by a doctor? (yes or no)

Yes

No

Any foreign pieces of metal or been injured by a bullet, pellet or shrapnel? *

Yes

No

Where in the body? (type box)

Any joint replacements, pins, plates, rods, screws, or nails in your bones? *

Yes

No

Do you suffer claustrophobia? *

Yes

No

Female only patients

Do you have an implanted contraceptive device (e.g. IUD)? *

Yes

No

Are you pregnant or suspect you are pregnant? *

Yes

No

Are you currently breast feeding? *

Yes

No

MRI contrast administration

For some MRI examinations, contrast dye may be required to improve the imaging of organs and tissues.

Do you consent to contrast dye being used *

Yes

No

Do you have renal (kidney) failure *

Yes

No

If you have any allergies, please list them

Next appointment with you doctor

Do you have an appointment with your doctor to discuss the results of the scan? *

Yes

No

What date is your appointment booked for? *

Upload documents

To assist us with your appointment, please upload a copy of your request form (if you were provided one by your doctor). Additionally, you can also upload a copy of any previous report you have. Please note: If you were provided a copy of your request form, please still bring this to your MRI appointment.

Upload request form

Only .DOC, .DOCX, .PDF, .RTF, .ZIP, .RAR, .GIF, .PNG and .JPG files (less than 5MB) accepted.

Pre examination information

It is likely you will be required to change into a gown prior to your examination. Your personal items will be stored securely. Before your scan you must remove all metal objects in your possession or on your body. This includes watches, mobile phones, credit cards, coins, keys, body piercings, earrings, hair clips, hearing aids, dentures, jewellery etc.

Disclaimer

I acknowledge to the best of my understanding that the above answers are true and correct and I consent to the MRI examination. Further, I acknowledge that Benson Radiology has taken reasonable precautions and is not liable for any event that might result from incorrect answers on this form.

Disclaimer acknowledgement *

I acknowledge the disclaimer

Signature *

Staff member name consenting patient

Leave this field blank

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