Screening Questions

Do you have...
a cardiac pacemaker? yes, no
an intracranial aneurysm clip? yes, no
dentures/partials? yes, no
a hearing aid? yes, no
a hair piece? yes, no

Scan Related
Height ______
Weight ______
Are you able to lie flat? yes, no

Contrast Agent
Have you ever had IV MR contrast (Gadolinium)?
yes, no
Is there a possibility of pregnancy? yes, no

Surgery
Have you had brain or head surgery? yes, no
Have you had ear surgery? yes, no
Have you had eye surgery? yes, no
Have you had other surgery? yes, no
Have you had artificial implants? yes, no

History
Anemia: yes, no
Seizures: yes, no
Kidney Disease: yes, no
Asthma: yes, no
Bullets, Shrapnel, BB: yes, no
Pierced body parts: yes, no
Hx of metal fragments in eye: yes, no

Other
Drug allergies/reaction: ____________