EFTA00313928.pdf

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