Rev. 05/10/2012

Biomedical Imaging Center

Beckman Institute for Advanced Science and Technology

University of Illinois at Urbana-Champaign

Adult Research Participant Medical History and Safety Screening

Please answer ALL of the following questions:

Date: ______Name: ______

Female Male Age: _____ Date of birth: ______Height: ft.__ in.__ Weight____

Handedness: Right Left E-mail: ______Phone: (____)____-______

Certain items or conditions can interfere with MR imaging quality or present a safety hazard in an MR environment. Please check if you have any of the following items: (must check each question with a “Yes” or “No” response)

Basic History Yes No

1. Have you ever had an MRI before? If yes, which part(s) of the body were scanned? ______

2. Have you ever been scanned at the Biomedical Imaging Center before? If yes, please provide approximate date and/or study.

______

3. Have you ever experienced any problem related to an MRI examination or MRI procedure? If yes, please describe: ______

4. Are you claustrophobic?

5. Have you ever had a surgical operation, or procedure of any kind?

If yes, please list all prior surgeries and the approximate year of each:

______

______

6. Are you allergic to animal dander?

7. Is there any chance that you could be pregnant?

**Please inform the technologist if you suspect that you could be pregnant.**

Chest Yes No

8. Do you have a cardiac pacemaker?

9. Do you have an implanted cardioverter defibrillator (ICD)?

10. Do you have aortic clips?

11. Have you had open heart surgery?

12. Do you have any staples, clips, or wire sutures?

13. Do you wear a transdermal patch (nicotine or nitroglycerin)?

14. Do you have an artificial heart valve? Model # ______

15. Do you have an arterial stent? If yes, approximate date of surgery and the location of the stent/s: ______

16. Do you have any tissue expanders? (i.e. breast)

17. Do you have any vascular access port and/or catheter?

Cosmetic

18.  Do you have permanent eyeliner?

19.  Do you have tattoos? If so, where are they located?

______

20.  Are you wearing a wig?

21. Do you have a weave?

22. Do you have ANY body piercings? Location______

23. Do you wear removable dentures, false teeth, or a partial plate?

24. Are you wearing an orthodontic retainer or have braces?

Foreign Bodies

25. Have you ever performed metal work such as, grinding, soldering, or welding?

26. Have you ever been injured in your eye by metal objects or metal shavings? If yes, please describe.

______

Foreign Bodies, continued….. Yes No

27. Have you ever been injured by a metallic object or a foreign body such as a bullet, BB, shrapnel, or nails? If yes, please describe. ______

______

28. Do you have metal fragments in your head, eyes, or skin that are not indicated above? If yes, please describe. ______

Head

29. Do you have any known brain malformations? If yes, please specify type and location. ______

30. Do you have intracranial aneurysm clips?

31. Do you have a spinal or ventricular shunt/s?

32. Do you have a cochlear, otologic, or other ear implant(s)?

33. Do you have a stapedectomy? Do you have a stapes prosthesis?

34. Do you have hearing aid/s? If so, are you wearing them?

Orthopedics

35. Have you had fractured bones treated with rods, metal plates,

pins, screws, nails, or clips? If yes, please specify type and location.______

36. Do you have an artificial eye or an eyelid spring?

37. Do you have bone stimulators?

Abdomen/Pelvis

38. Do you have magnetically-activated implant(s) or device(s)?

39. Do you have a vagal nerve stimulator/pain pump?

40. Do you have an insulin pump?

41. Do you have any implanted drug infusion devices?

42. Do you have metal mesh implants?

43. Have you undergone surgery for a hernia?

44. Do you have any implanted radiation seeds or implants?

Abdomen/Pelvis, continued….. Yes No

45. Do you a penile implant? Model # ______

46. Do you have an implanted I.U.D. (intra-uterine device)? If so, please include the model number and the year in which it was put in place.______

47. Do you have a diaphragm?

48. Do you have a pessary?

Prosthetics

49. Do you have any type of implant held in place by a magnet?

Model #______

50. Do you have an artificial eye or an eyelid spring?

Spine

51. Do you have neurostimulators in place? (TENS unit)

52. Do you have a Harrington rod for scoliosis?

53. Do you have a spinal cord stimulator?

Thank you for your thoughtful attention to these questions. Your safety as a research participant is our primary concern.

By signing below, you acknowledge that you have carefully read and answered each question to the best of your ability.

Research Participant Printed Name: ______

Research Participant Signature: ______

MRI Technologist Signature: ______

Signature of Witness: ______

Date: ______

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