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AegysPro-MR MRI Screening Form Mobile App

Magnetic Resonance Imaging (MRI) uses a powerful magnetic field to produce very clear images of the human body. When you are in the scan room any metallic objects on or within your body could be affected by the magnetic field. Therefore, all individuals are required to fill out this form before entering the MR environment or MR system room. Be advised, the MR system magnet is ALWAYS on and the strong magnetic field is always present. Fill out this digital MRI Screening Form without the use of Wi-Fi or paper to make sure all individuals entering the scan room have no metallic objects on their body and that they fully understand all the safety procedures as well as the dangers and risks of not fully complying to the safety procedures.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the AegysPro-MR MRI Screening Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Magnetic Resonance Imaging (MRI) uses a powerful magnetic field to produce very clear images of t...

  • Ico statictext

    Be advised, the MR system magnet is ALWAYS on and the strong magnetic field is always present.

  • Ico statictext

  • Ico textbox

    Your Name

  • Ico date

    Date of Birth

  • Ico textbox

    Weight

  • Ico textbox

    Height

  • Ico dropdown

    Gender (Choose One)

  • Ico statictext

  • Ico statictext

    Please indicate by checking yes or no for each of the following:

  • Ico dropdown

    Have you ever had a surgical procedure or operation of any kind?

  • Ico multiline

    If yes, please list all operations and give approximate dates

  • Ico dropdown

    Have you ever worked as a machinist, grinder, welder, or have you ever had an injury to the eye i...

  • Ico multiline

    If yes, please describe

  • Ico dropdown

    Have you ever been injured by a metallic foreign body (bullet, BB, shrapnel etc.

  • Ico multiline

    If yes, please describe

  • Ico statictext

  • Ico statictext

    Remove all metallic objects before entering the MR environment or MR system room including (these...

  • Ico statictext

    • hearing aids • pager • cell phone • keys • eyeglasses • dentures • hair pins • barrette • jewel...

  • Ico statictext

    Loose metallic objects are especially prohibited in the MR system room and MR environment.

  • Ico statictext

    Please turn to screen 2 and complete the questionnaire.

  • Ico statictext

    Some of the following items may be hazardous to your safety and some can interfere with the MRI e...

  • Ico statictext

  • Ico statictext

    Do you have any of the following?

  • Ico dropdown

    Cardiac pacemaker

  • Ico dropdown

    Implanted cardiac defibrillator

  • Ico dropdown

    Aneurysm clip(s)

  • Ico dropdown

    Carotid artery vascular clamp

  • ...and More!

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