MR Pre-Screening

Participant details

Date

Participant name

Sex

Date of Birth

Weight (kg)

Height (cm)

MRI screening

1. Did you ever have a problem in any past MRI examination?

Yes No

2. Do you currently have anything in your body that was added after you were born, including implants, prostheses, clips, stents, coils, mesh, joint replacements, screws, rods, pumps, stimulators or another implanted device?

Yes No

3. Do you have a pacemaker, implantable defibrillator (ICD), deep brain stimulator, vagus nerve stimulator, spinal cord stimulator or artificial heart valve?

Yes No

4. Do you have any aneurysm clips, shunts, vascular stents or coils, a cochlear implant or another internal electronic or magnetic device?

Yes No

5. Did you ever have metal fragments in your eye or body, such as bullet fragments, shrapnel, BB (Air Gun) pellets, splinters or industrial metal fragments?

Yes No

6. Do you have any metal implant or metal-containing device (except routine dental fillings or crowns), such as orthopedic hardware, an artificial joint, penile implant, artificial eye, eyelid spring or another object that could be attracted to a magnet?

Yes No

7. Do you have a metallic dental brace, bracket, dental implant or any removable dental or orthodontic appliance?

Yes No

8. Do you wear a hearing aid or another removable hearing device processor?

Yes No

9. Are you wearing or using any external medical device, patch, or pump, such as an insulin pump, continuous glucose monitor, medication patch, TENS unit, Holter monitor or implanted medication pump?

Yes No

10. Were you ever affected by one of the following conditions: epilepsy, diabetes, problems in body temperature regulation?

Yes No

11. Do you have circulation or respiration problems?

Yes No

12. Do you suffer from claustrophobia?

Yes No

13. Do you have neck or back pain?

Yes No

14. Do you have any tattoos (including those with metallic-looking effects), permanent makeup, piercings, metallic makeup, magnetic eyelashes or cosmetic products containing metallic particles?

Yes No

15. Are you wearing any jewelry, body piercing, hair accessory, clothing, or footwear with metal that cannot be removed before the scan?

Yes No

16. Are you currently taking any medication?

Yes No

17. Do you wear a wig or hair piece, especially one with metal parts or clips?

Yes No

18. Is there any possibility that you are pregnant?

Yes No

19. Have you been sterilized with clips?

Yes No

20. Do you wear an intrauterine device (spiral or IUD)?

Yes No

21. Are you currently breast-feeding?

Yes No

22. Handedness

Left Both Right

Consent

I confirm that the information is correct.

Incidental Findings

This study serves only for scientific purposes, there is no physician-patient-relationship between the examiner and the participant. Data acquired with MR Sequences used in scientific research are not suitable for diagnostics and will only be reviewed by an expert in neuroradiology if they show obvious abnormalities. If the expert confirms findings that need diagnostic clarification, we will contact you with a recommendation for clinical diagnostics. Further diagnostics and any resulting expenses are not covered by this examination and will need to be paid by you or your health insurance.

A clinically confirmed incidental finding can lead to an early diagnosis of a disease and thereby increase chances of positive outcome. However, diagnostics could reveal findings that are not or only partially treatable. Additionally, there might be adverse consequences in terms of employment and for future insurance applications.

I have read and agree to the information about incidental findings.

I agree to be contacted by phone regarding further diagnostic clarification if needed.

Yes No

Phone number

Participant instructions

Use the ear plugs we provide. MRI produces high noise levels and hearing protection is required.
Before the scan, remove all jewelry and body piercings, hair accessories with metal, removable dental or orthodontic items, hearing aids or processors, glasses, watches, phones, cards, keys, coins, lighters, tools, pens, and other loose metal or magnetic objects.
Use MRI-safe clothing provided by the facility, or remove clothing and footwear with metal parts such as zippers, buttons, snaps, hooks, rivets, studs, belt buckles, underwire, steel toes, metal shanks, metal eyelets, or decorative metal components.
Tell MRI staff before the scan if you are wearing an external medical device or patch, or if you have any implant, prosthesis, stimulator, pump, clip, stent, coil, joint replacement, metal fragment, or other metal in your body.
Tell MRI staff if you have tattoos, permanent makeup, metallic cosmetics, magnetic eyelashes, or nail products containing metallic particles.

Signature

Participant signature

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