MRI Safety Questionnaire MRI SAFETY QUESTIONNAIRE Prior to the examination, this form must be completed by the patient or guardian and signed. Some of the following items may be hazardous in the scanner. TitleMrMrsMsMiss Your First Name (required) Your surname (required) Your Email (required) Your Date of birth Referral upload*(Click "Choose File" button below to attach or take a photo of your referral for upload): Please ensure you capture the entire referral form. Have you ever had surgery of your: Head YesNo Heart YesNo Inner Ear YesNo Inner Ear YesNo Renal Transplant YesNo Do you have any of the following? Neural Stimulator YesNo Cardiac pacemaker or pacing wires or Cardiac Defibrillator YesNo Aneurysm clips (surgical clips on arteries in your brain) YesNo Ear lmplants YesNo Eye Implants YesNo Stents/Heart Valves YesNo Bowel Clips(any recent bowel surgery?) YesNo Tissue Expanders (Breast or Penile) YesNo Hearing aid (to be removed before scan) YesNo Dentures (to be removed before scan) YesNo Magnetically implanted dental devices YesNo Any other magnetic, electronic or metallic implants or devices YesNo If yes, please list: Do you wear any medication patches?YesNo Have you ever had metal fragments in your eyes?YesNo Do you have any tattoos less than 4 weeks old (including cosmetic)YesNo Are you a diabetic? YesNo Have you had a recent blood test for kidney function? YesNo Are you pregnant or breastfeeding? YesNo Have you ever had an allergic reaction to MRI contrast? YesNo Do you suffer from claustrophobia? YesNo Have you ever had an MRI scan before?YesNo If yes; Where When Who has the images? I the patient or substitute decision maker, confirm that I have read and/or been read and understand these questions and have answered them correctly.