Contraindication

YES

NO

• Cardiac pacemaker

• Aneurysm clip(s) in the brain

• Implanted cardiac defibrillator

• Any type of biostimulator/neurostimulator

• Any type of electronic, mechanical or magnetic implant Type: _______________________

• Implanted drug infusion device

• Implanted insulin pump

• Any type of metallic foreign body, shrapnel or bullet

• Any metal shavings in eyes (machinist or metal worker)

• Any type of intravascular coil, filter or stent (Greenfield IVC filter)  Date:__________

• Any type of internal electrode(s), including Pacer wires

• Cochlear implants (ear implants)

• Orbital eye prosthesis (eye implant)

• Holter Monitor

Additional Information

YES

NO

• Heart valve prosthesis   Type:___________________________

• Halo vest or metallic cervical fixation device

• Any type of surgical clip or staple(s)

• Vascular access port

• Intraventricular shunt

• Any implanted orthopedic item(s) (i.e., pins, rods, screws, nails, clips, plates, wire etc.)
 
Type: ____________________________________
 
Location:__________________________________

• Pessary

• IUD/Diaphragm

• Artificial limb or joint

• Permanent eye liner/Tattoo

• Body ring/Spike

• Hearing Aid

• Does patient weight 300 pounds or more?

• If female patient, is she pregnant?   LMP:__________________

Medication/Sedation

YES

NO

• Is patient able to cooperate ? (must be able to lie still for approx. 1 hour)

• Is pain medication required for patient cooperation?

• Is sedation required for claustrophobia?