MRI safety questionnaire

Please complete this form on behalf of your child.

Your child’s details

Child’s name:

Date of birth:

Weight:

Address:

Contact number:

Date:

Hospital number (staff use only):

Health details

Has your child ever had any surgery to their heart or chest?  Yes  No

If yes, provide the date, hospital and what procedure was done:

Has your child ever had any brain surgery?  Yes  No

If yes, provide the date, hospital and what procedure was done:

Has your child ever had any metal fragments in their body after an accident?  Yes  No

Has your child got an electronic implant in their body?  Yes  No

Has your child ever had an examination of their abdomen with a camera being inserted?  Yes  No

Could your child be pregnant?  Yes  No

Date of last period (if relevant): 

Has your child had surgery of any kind in the last 12 months?  Yes  No

If yes, provide the date, hospital and what procedure was done:

Does your child suffer from any heart disease or rhythm disorder? Yes  No

Does your child have any hearing problems? Yes  No

Does your child have any kidney problems? Yes  No

Does your child wear any removable metal dental work? Yes  No

Does your child have epilepsy or diabetes? Yes  No

Does your child have any allergies? Yes  No

Does your child have any other metallic objects in their body not mentioned above? Yes  No

If yes, please specify:

Your child will be asked to remove all items which may be affected by the magnetic field, including:

• coins
• keys
• mobile phone
• credit cards
• glasses
• hearing aids
• hair clips
• skin patches
• jewellery (including body piercings)

Lockers are available to store any items in the waiting area.

If you have read and understand the above restrictions, please sign below

Signature:

Date: