Name: Cre_Fr- r2C--
Name: Cre_Fr- r2C--
Date of Birth: ,)A ri 5-3 Height: 5 I I hi Weight I 7:C, Social Security
Some of the foliating items may be hazardous to your safety or can interfere with you MRI/MRA examination.
Please check YES or NO for each of the following Items.
YES NO
Cardiac Pacemaker or °inhalator
Brain Aneurysm Clip (s)
Transdermai Patch: Nicotine I Nitroglycerine
Shunts (e.g. Spinal / intraventricular/ VP shirt)
Bone Growth /Fusion stimulator
NeurosWSator
Cochlear /0tologic / Ear Implant
Implanted Drug Infusion Device/Insulin Pump
Bectrodes (on body, heed or brain)
Any Implant Held In Place by Magnet
Carotid Artery Vascular Clamp
Intravascular slants, filters, or coils
Vascular Arrsts Port and/or Catheter
Swan-Ganz Catheter
Internal Pacing Wires
My type of prosthesis: eye,penlit etc
Metal or Wire Mesh Implants
Remington Rods (spine)
(Joint Replacement
Bone/Joint pin, screw, nail, wire, plate
Body piercing (s)
Tattooed Makeup (eyeliner, ups. etc)
Any Metal Fragments
IUD or Diaphragm
Hearing aid (remove before MRVMRA)
Dentures (remove before MRI/MRA)
AsWns or other breathing disorder
Arodely
Other.
Patient Signature: \
MR; Screera!ng For. 1C:22/12 1. What problems are you having that made the
doctor order this study?
2. Have you ever been to the hospital for an
Invasive procedures or surgery? Yes / No
Qua Reasoq
3. Have you ever had an accident that required
metal fragments to be removed from your eye?
4_ Women. Could you is pregnant? Yes I Na
5. Do you have a history of kidney disease?
Yes I No
6. Do you have sickle cell anemia? Yes I No
7. Have you had an allergic reaction that required
emergency treatment? Yea / No
8. Do you or nave you:
High blood pressure? Yes I No
Diabetes?
High cholesterol?
Smoked tobacco? Yes I No
Yes / No
Yos I No
9. Do you have chest pain? Yes / No
If yes:
Is it substemar? Yes I No
Is it brought on by exertion or emotional stress?
Yes I No
Is it relieved by rest or nitroglycerine? Yes I No
Date: 3.74 03DOI ?
EFTA00313934