You are being scheduled for an MRI and/or MRA imaging procedure. Please tell us about everything placed in or on your body, even if you have had MRI scans before, as additional information may be needed prior to performing the exam.

Electronic devices

• Heart pacemaker
• Heart defibrillator
• Heart rhythm/cardiac recorder
• Nerve stimulator
• Pain medication pump
• Diabetic insulin pump – disposable or permanent

Ever had metal in eye(s)?

• Yes
• Yes, but was removed
• Yes, but more than five years ago
• Yes, but have had MRI since metal in eye(s)
• Never

Implants

• Cochlear ear implant
• Breast tissue expander
• Heart valve replacement
• Heart stent(s)
• Other stent(s)
• Blood vessel coil
• Blood vessel filter
• Blood vessel graft
• Penile prosthesis
• Body modification implant(s)

Surgery on head/ear

• Inner ear reconstruction
• Stapes implant/replacement
• Cochlear ear implant
• Aneurysm coil
• Aneurysm clip
• Shunt

Medical history

• Kidney disease
• Diabetes
• Pregnant/possibly pregnant

Other items

• Claustrophobic
• Hearing aid(s)
• Shrapnel or gunshot wound
• Artificial limb
• Body piercing (other than ear)
• GI camera pill swallowed
• Medication patch
• Allergy/sensitivity to medicines or Latex
• Breast feeding