Name: F E_PSTEJ
Name: F E_PSTEJ
Date of Birth: TA ri -* Height: ()E I I " Weight: I 7' Social Security I:
Some of the following items m.ay be hazardous to your safety or can interfere with you MRIIMRA examination.
Please check YES or NO for each of the following items.
YES NO
Cardiac Pacemaker or Deflbrelator
Brain Aneurysm clip (s)
Transdermal Patch: Nicotine / Nitroglycerine
Shunts (e.g. Spinal I intraventriculad VP shunt)
Bone Growth /Fusion stimulator
Newesemulator
Cochlear /Otologic / Ear Implant
Implanted Drug Infusion Device / insulin Pump
Electrodes (on body, heed or brain)
Any implant Held In Piece by Magnet
Carotid Men/ Vascular Clamp
Intravasc.lar stents, fitters, or cols
Vasatlar Access Port and/or Catheter
Swan-Gana Catheter
Internal Pacing Wires
My type of prosthesis: eye,penile. etc
Metal or Wire Mesh Implants
Harrington Rods (spine)
Joint Replacement
Bone/Joint On, screw, nail, wire, plate
80470=61e 60
Tattooed Makeup (eyeliner, ups, Mc)
Any Metal Fragments
IUD or Diaphragm
Hearing ad (remove bebre MRI/MRA)
Dentures (remove Debra MRI/MRA)
Asthma or other breathing disorder
Arudsty
Other:* 1. What problems are you having that made the
doctor order thlis sbxty?
2. have you ever been to the hospital for an
invasive procedures or surgery? Yes / No
Dale Reason
3. Have you ever had an accident that required
metal fragments to be removed from your eye?
4_ Werner.; Could you 4:41 pregnant? Yea / No
5. Do you have a history of kidney disease?
Yes / No
6. Do you have sickle cell anemia? Yes / No
7. Have you had an allergic reaction that required
emergency treatment? Yes / No
8. Do you or have you:
High blood pressure?Yes / No
Diabetes? Yes / No
High cholesterol? Yes I No
Smoked tobacco? Yes / No
9. Do you have chest pain? Yes / No
If yes
Is it substemal? Yes / No
Is it brought on by exertion or emotional stress?
Yes / No
is it relayed by rest or nitrogdycarine? Yes I No
Patient Signature: Date: JAI 1-. ?
stRi Screerme Form.: 10/22112
EFTA00313928