EFTA00313934.pdf

Name: Cre_Fr- r2C-- 5 -3 Height: 5 I I hi Weight I 7: C, Social Security Date of Birth: ,)A ri examin ation. your safety or can interfere with you MRI/MRA Some of the foliating items may be hazardous to Please check YES or NO for each of the following Items. YES NO 1. What problems are you having that made the doctor order this study? Cardiac Pacemaker or °inhalator Brain Aneurysm Clip (s) Transdermai Patch: Nicotine I Nitroglycerine Shunts (e.g. Spinal / intraventricular/ VP shirt) Bone Growth /Fusion stimulator 2. Have you ever been to the hospital for an Invasive procedures or surgery? Yes / No NeurosWSator Cochlear /0tologic / Ear Implant Qua Reasoq Implanted Drug Infusion Device/Insulin Pump Bectrodes (on body, heed or brain) Any Implant Held In Place by Magnet 3. Have you ever had an accident that required Carotid Artery Vascular Clamp metal fragments to be removed from your eye? Intravascular slants, filters, or coils Vascular Arrsts Port and/or Catheter 4_ Women. Could you is pregnant? Yes I Na Swan-Ganz Catheter Internal Pacing Wires 5. Do you have a history of kidney disease? Yes I No My type of prosthesis: eye,penlit etc Yes I No 6. Do you have sickle cell anemia? Metal or Wire Mesh Implants Remington Rods (spine) 7. Have you had an allergic reaction that required emergency treatment? Yea / No ( Joint Replacement Bone/Joint pin, screw, nail, wire, plate 8. Do you or nave you: Body piercing (s) High blood pressure? Yes I No Diabetes? Yes I No Tattooed Makeup (eyeliner, ups. etc) High cholesterol? Yes / No Any Metal Fragments Yos I No Smoked tobacco? IUD or Diaphragm No 9. Do you have chest pain? Yes / Hearing aid (remove before MRVMRA) If yes: Dentures (remove before MRI/MRA) Is it substemar? Yes I No AsWns or other breathing disorder Is it brought on by exertion or emotional stress? Yes I No Arodely Other. Is it relieved by rest or nitroglycerine? Yes I No \ Date: 3 .74 03DOI ? Patient Signature: MR; Screera!ng For . 1C:22/12 EFTA00313934