MRI Metal Checklist

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