MRI Questionnaire

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To display all questions and their answers, this form is designed for landscape mode.

📋 Patient information

LAST NAME :

FIRST NAME :

Date of birth :

Weight :

Height :

Address :

Home phone * :

Mobile * :

Email * :

* Required: at least one 10-digit phone number and a valid email address.

GP / Referring physician :

Limited mobility (wheelchair, stretcher) :

YES NO

Ambulance arranged :

YES NO

⚠️ Please read each question carefully and correct if needed.

⚠️ Important information — Please read carefully

Your doctor has requested an MRI scan. The MRI machine is a powerful magnet. This examination cannot be performed if you have a PACEMAKER or an implantable CARDIAC DEFIBRILLATOR. To carry out the examination, you MUST inform us of any metal implants or objects inside your body.

♀ For women only

Are you pregnant or could you be pregnant?

YES NO

Are you breastfeeding?

YES NO

Is your period late?

⚠ If YES, a pregnancy test is required before the MRI.

YES NO

💉 If contrast injection is needed

Have you ever had an allergic reaction after a radiology examination with injection?

(rash, itching, swelling…)

YES NO

Patient information leaflets about the examination procedure are available at the reception desk. Please take a moment to read them.

An intravenous contrast injection may be required. It is painless and generally well tolerated. However, any injection carries risks:

Painful redness at the injection site — disappears within a few days.
A minor, transient skin rash may occur.
Unforeseeable complications (extremely rare).

🚫 Items to remove before the examination

💍 Jewellery 📿 Piercings 🦷 Metal dental appliance 👂 Hearing aid

Example: HEAD MRI
with orthodontic appliance

If necessary, a remote radiologist may be consulted.
In this case, I give my consent to Dr MORALES to use teleradiology for the interpretation of images taken during my examination.

✍️ Patient declaration

Full name :

I have personally completed this form, certify that I have read and understood its content, and give my consent for the examination to be carried out.

Date :

Signature :

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CABINET TESLA — MEDICAL IMAGING CENTER

Cognac Clinic • Dr Pierrick MORALES