MRI Exam Preparation Checklist Form
Please complete this checklist to verify your MRI exam details, screening status, and readiness. Review each item to ensure you are prepared for your MRI exam.
Patient Full Name
*
First Name
Last Name
MRI Exam Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Exam Type / Body Area
*
Please Select
Brain/Head
Spine (Cervical/Thoracic/Lumbar)
Abdomen/Pelvis
Joints (Knee/Shoulder/Hip/Other)
Other
Do you have any implanted metal devices (e.g., pacemaker, cochlear implant, aneurysm clips, metal fragments, joint replacements)?
*
No, I do not have any implanted metal devices
Yes, I have one or more implanted metal devices
Not sure
Do you have a history of claustrophobia or anxiety in enclosed spaces?
*
No
Yes, mild
Yes, severe
Are you currently pregnant or is there a chance you may be pregnant?
*
No
Yes
Not applicable
Have you received and followed all MRI preparation instructions (e.g., fasting, medication adjustments, removing metal objects)?
*
Yes, I have followed all instructions
No, I have questions or concerns
Will you require assistance with transportation or an escort after your MRI exam?
*
No, I do not need assistance
Yes, I will need transportation or an escort
Please confirm that you understand the MRI exam preparation requirements and are ready for your appointment.
*
I understand and am ready for my MRI exam
I have questions and need further assistance
Submit Checklist
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