MRI Screening - Medical Associates of Northwest Arkansas

Name

First Last

Date of Birth*

MRI Appointment Date

Do you have a pacemaker or defibrillator?*

Do you have internal electrodes or wires?*

Have you had an aneurysm clip(s) or any brain surgery?*

Do you have a neurostimulator-TENS Unit, bone growth stimulator, or spinal cord stimulator?*

Do you have an artificial limb or prosthesis?*

Do you have an ear (Cochlear) implant or middle ear implant?*

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

Do you have a shunt or Sophy adjustable and programmable pressure valve?*

Do you have a tissue expander from a recent breast cancer surgery?*

Do you have a penile implant?*

Do you have a external or implanted drug pump?*

Have you had any eye surgery?*

Have you had any stents?*

Have you had a body or eye injury from metal objects like metal shavings, shrapnel, or bullets?*

Do you have a history of allergic reaction to MRI contrast?*

Are you pregnant?*