DS9 Document EFTA00313934

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