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Safety Questionnaire
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Before your exam · Fill in online

Safety Questionnaire
online.

Answer the safety questionnaire for your exam calmly, at home. Our team receives your answers already in the official form format and uses them to triage and prepare your visit — on the day of the exam the questionnaire is ready: you review your answers with our team and only need to sign, at the clinic.

Before you start

This form has been validated by CRMA's Clinical Board and Data Protection Officer. Filling it in online is optional and does not replace the official questionnaire: your answers are reviewed with you at the clinic, where the questionnaire is signed. For exams with contrast (MRI and CT), contrast authorisation is always decided and signed in person, after your questions have been answered with the team. If you don't know an answer, leave it blank or choose “I don't know” — we'll clarify it with you. Your answers are processed under the Privacy Policy.

This form needs JavaScript enabled (the questions open depending on the exams you select). If you can't enable it, download the PDF forms on the safety questionnaire page or call +351 289 892 100.

Your details

Full name *

Date of birth *

Phone *

Email *

Do you already have a booking at CRMA?

Booking date (if known)

Your exam(s)

Select the exam(s) you are going to have — you can choose more than one. If you came from a booking request, the ones that apply are already ticked. For each exam you tick, its block of questions opens below. Answers shared by several exams (for example, your weight or pregnancy) are filled in automatically in the other blocks once you give them.

MRI CT scan Mammography Bone densitometry (DEXA)

Select at least one exam.

MRI

MRI uses a very strong magnetic field — if you have a prosthesis or implant, these questions are essential.

Before we start

Have you had an MRI before? Yes No I don't know

If yes, for what?

Have you had surgery? Yes No I don't know

If yes, for what?

Implants and devices

Do you have a pacemaker or an implantable cardioverter-defibrillator (ICD)? Yes No I don't know

Do you have artificial heart valves? Yes No I don't know

Do you have stents (vascular prostheses)? Yes No I don't know

Do you have aneurysm clips or coils (cerebral, aortic or other)? Yes No I don't know

Do you have a hearing aid and/or a cochlear implant? Yes No I don't know

Do you have a dental implant, prosthesis, plate and/or brace? Yes No I don't know

Do you have a shunt or valve (spinal or ventricular)? Yes No I don't know

Do you have a neurostimulator or biostimulator? Yes No I don't know

Do you have metal orthopaedic prostheses, plates, screws or pins? Yes No I don't know

Do you have a medication infusion pump (internal or external, e.g. an insulin pump)? Yes No I don't know

Do you have an implanted or subcutaneous glucose monitor? Yes No I don't know

Do you have a weight-loss device (gastric band or balloon)? Yes No I don't know

Do you have a penile prosthesis, an eye prosthesis, or a spring/wire in the eyelid? Yes No I don't know

Do you wear a medicated adhesive patch on your skin (e.g. nicotine, nitroglycerin)? Yes No I don't know

Do you have metal filings, lead shot and/or shrapnel in your body? Yes No I don't know

Have you ever had an eye injury with a metal object/fragment, OR do/did you work with metals (welder, metalworker, lathe operator)? Yes No I don't know

Do you have tattoos and/or piercings? Yes No I don't know

If you have any implant/device, state the make/model and bring its implant card

Health and allergies

Do you have claustrophobia? Yes No I don't know

Do you have asthma or bronchitis? Yes No I don't know

Do you have any allergies (medicines, food, other)? Yes No I don't know

If you have allergies, to what?

Do you have renal impairment? Yes No I don't know

Do you undergo haemodialysis? Yes No I don't know

Have you had examinations with a contrast injection before? Yes No I don't know

Have you ever had an allergy to injected contrast? Yes No I don't know

If you are female

Do you have a breast tissue expander? Yes No Not applicable

Do you have an intrauterine device (IUD)? Yes No Not applicable

Are you pregnant? Yes No Not applicable

If you are pregnant, how many weeks?

Are you breastfeeding? Yes No Not applicable

Additional information

Weight (kg)

CT scan

Questions from the official CT questionnaire and consent for iodinated contrast.

Questionnaire

Have you had an examination with iodinated contrast before (CT, angiography, urography)? Yes No I don't know

Have you ever had a reaction to iodinated contrast? Yes No I don't know

Do you have asthma under medical treatment? Yes No I don't know

Do you have severe allergies that have needed treatment (e.g. a severe allergic reaction)? Yes No I don't know

Do you have kidney disease or renal impairment? Yes No I don't know

Are you on dialysis? Yes No I don't know

Do you have diabetes? Yes No I don't know

Do you take metformin or antidiabetic medicines that contain it (e.g. Glucophage, Stagid, Risidon, Janumet)? Yes No I don't know

Do you have thyroid disease, in particular hyperthyroidism/goitre (an “overactive” thyroid)? Yes No I don't know

If you are female: are you pregnant or possibly pregnant? Yes No Not applicable

Are you breastfeeding? Yes No Not applicable

Reaction to iodinated contrast (if YES) — severity

Allergies (if YES) — to what (medicines, food, other)

Regular medication

Weight (kg)

Mammography

Questions from the official mammography questionnaire — symptoms, history and hormonal status.

Weight (kg)

Height (m)

Date of last period (if applicable)

Current symptoms

Do you feel a lump in your breast? Yes No I don't know

Do you have persistent, localised pain in one breast? Yes No I don't know

Have you noticed recent nipple retraction, or eczema/flaking of the nipple? Yes No I don't know

Do you have any nipple discharge (especially from a single opening)? Yes No I don't know

Have you noticed a skin change (dimpling, “orange-peel” skin, thickening)? Yes No I don't know

If you answered YES, state which breast (R/L) and for how long

If you have nipple discharge, state the colour (you may choose more than one)

Clear/watery Whitish/milky Yellowish Greenish Brownish Pinkish Bloody/reddish I don't know

Does the discharge come out on its own or only when you squeeze the nipple? Comes out on its own (stains clothing/bra) Only when I squeeze

Breast history

Have you had a mammogram, breast ultrasound or breast MRI before? Yes No I don't know

Have you had a breast biopsy? Yes No I don't know

Have you had breast surgery (including cosmetic/reduction/augmentation surgery)? Yes No I don't know

Do you have breast implants or have you had breast reconstruction? Yes No I don't know

Have you had mastitis (breast inflammation)? Yes No I don't know

Have you had breast cancer? Yes No I don't know

Have you had ovarian cancer? Yes No I don't know

Did you have radiotherapy to the chest area between the ages of 10 and 30 (e.g. treatment for lymphoma)? Yes No I don't know

If you answered YES to any of the questions above — details (what / when / where / which breast, if applicable)

Family history

Do you have relatives with breast cancer? Yes No I don't know

Do you have relatives with ovarian cancer? Yes No I don't know

Is there a known genetic mutation in your family (e.g. BRCA)? Yes No I don't know

If YES, state the relationship and the age at diagnosis

Hormonal and reproductive status

Do you still have periods? Yes No I don't know

Have you reached the menopause? Yes No I don't know

Are you on hormone replacement therapy (HRT)? Yes No I don't know

Do you take hormonal contraceptives? Yes No I don't know

Have you had children? Yes No I don't know

Have you breastfed? Yes No I don't know

Are you pregnant or possibly pregnant? Yes No I don't know

Are you breastfeeding? Yes No I don't know

If you have reached the menopause, at what age?

If you breastfed, for how long?

Bone densitometry (DEXA)

Questions from the official bone densitometry (DEXA) questionnaire — interferences, risk factors and medication.

Basic details

Weight (kg)

Height (m)

Sex

Reason/indication for the examination

Referring doctor

Recent interferences

In the last few weeks, have you had any contrast examination (barium, iodinated, gadolinium or oral contrast)? Yes No I don't know

In the last few weeks, have you had nuclear medicine, scintigraphy or PET? Yes No I don't know

Have you recently taken Pepto-Bismol or liquid antacids containing aluminium? Yes No I don't know

If YES, state the examination and the date

Previous densitometry

Have you had bone densitometry (DEXA) before? Yes No I don't know

If YES — when and where (clinic/machine)?

Risk factors for osteoporosis and fracture

Have you ever had a fragility fracture (after a fall from standing height)? Yes No I don't know

Did your father or mother fracture a hip? Yes No I don't know

Do you currently smoke? Yes No I don't know

Do you drink 3 or more alcoholic drinks a day? Yes No I don't know

Do you take, or have you taken, corticosteroid tablets for 3 months or longer? Yes No I don't know

Have you been diagnosed with rheumatoid arthritis? Yes No I don't know

Did you reach the menopause before the age of 45? Yes No Not applicable

Do you have type 1 diabetes, untreated thyroid disease, chronic liver disease, malabsorption, renal impairment or hypogonadism? Yes No I don't know

Have you lost more than 4 cm in height over your lifetime? Yes No I don't know

Do you have a prosthesis or metal hardware in the hip/spine, scoliosis or spinal surgery? Yes No I don't know

If you have had a fracture, state the site and the year

Age at menopause (if applicable)

Current medication

Calcium Vitamin D Bisphosphonates / denosumab Hormone therapy / oestrogens Aromatase inhibitors

Other medicines

Pregnancy

Are you pregnant or possibly pregnant? Yes No Not applicable

To finish

Is there anything else you think is important to mention? (optional)

I agree that CRMA may process the personal and health data provided in this form to prepare my exam and carry out the safety triage, under the Privacy Policy. I understand that the official questionnaire is confirmed and signed at the clinic. *

Required answers are missing — please review the fields marked in red above.

Your answers are sent securely to the CRMA team and are not stored on this site. Alternatively, you can download the official form and bring it filled in.

Answers sent

Thank you. Your answers reached the CRMA team already in the official form format, ready for the day of your exam — at the clinic, you review everything with our team and sign the questionnaire. For exams that may involve contrast, authorisation is decided and signed in person, after your questions have been answered. If anything needs clarifying before then, we'll contact you by phone or email.

Safety Questionnaireonline.

Answers sent

Safety Questionnaire
online.