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MRN Patient Name MRI SAFETY SCREENING QUESTIONNAIRE INPATIENTS MRI SMH extension 92886 / FAX 94043 Height Patient Label MRI RRUMC extension 78745 / FAX 73782 Floor/Unit Bed Physician The following items may be harmful to you during your MR scan or may interfere with the MR examination. Please provide a yes or no answer for every item. YES NO Cardiac pacemaker or implanted cardiac defibrillator/ICD Internal electrodes or wires pacing wires DBS or VNS wires Artificial heart valve coil filter...

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