Northern Beaches Medical Imaging

Staff MRI Questionnaire

Staff Member’s Name: Role:

The MRI Suite is a controlled environment for the safety of staff, patients and visitors. For this
reason all staff must complete this questionnaire in order for MRI staff to have advanced knowledge
of which staff members may or may not be permitted access to the MRI rooms.
Do NOT Enter the MR Scan room or MRI environment if you have any question or concern regarding
an implant, device or object. You must NOT enter the scan room with any of the following:
 Any metal object  Mobile phone  Hearing aids
 Credit cards/wallet  Pens/pencils  Belts
 Watch/keys  Hair clips/pins  Scissors/Clamps

Do you have ANY of the following:

Cardiac Pacemaker Yes No
ICD (defibrillator) Yes No
Heart valve replacement Yes No
Abdominal aortic stent Yes No
Intracranial aneurysm clips Yes No
Cochlear or other ear implant Yes No
Neurostimulation system Yes No
Implanted drug infusion pump Yes No
Magnetic breast tissue expander Yes No
Any metallic fragment or foreign body in any part
of your body Yes No
Electrodes, wires, catheters, ports Yes No
Shunts Yes No
Any type of prosthesis Yes No
Lens replacement (replaced in the 1980s) Yes No
Metal fragments in eyes or worked as a metal worker Yes No

 I have viewed the Lumus Imaging MRI Safety presentation

 I understand that it is my responsibility to inform the MRI Staff/Imaging Department if the status of
any of the above changes to ensure ongoing safety in the MRI department.

Staff signature: Date: