The Mount Sinai Hospital Mount One Gustave L. Levy Place Sinai Doctors New York, New York 10029 Name: DOB: Gender: M / F _/_/ MRN: DEPARTMENT OF RADIOLOGY MAGNETIC RESONANCE IMAGING (MRI) PATIENT SCREENING QUESTIONNAIRE Location: Physician: INSTRUCTIONS: Please answer each question below. Your responses will allow us to determine your eligibility for an MRI scan. Each box should be marked individually—please do not simply draw a line down a column. Yes No O O 1. Do you have a pacemaker, AICD, internal pacing wires, EKG leads or Hotter monitor? O O 2. Have you had brain surgery or do you have metallic clips (aneurysm clips) in your head? O D 3. Do you have an implanted stimulator (including bone growth stimulator, spinal stimulator or cochlear or other ear implant) or medication infusion pump? O O 4. Have you ever had eye surgery or implants? jp Ej 5. Have you ever worked around a metal lathe, had metal shavings or fragments in your eye(s), or had a shrapnel (war or gunshot) injury anywhere in your body? • O 6. Have any devices (e.g., stent, titter, coil or vascular port/catheter) been placed in your blood vessels? O O 5a. If you do have a stent, is it drug-eluting? O O 7. Do you have an implanted tissue expander? O O 8. Do you have a replaced heart valve, other prosthesis or any other surgical implant? O O 9. Do you have any tattoos, permanent make-up, or plercings? O O 10. Do you wear hearing aid(s), either in the ear canal or on the surface? (Remove before entering mom) O O 11. Do you wear a transdermal medication patch (e.g., Nitroglycerin, Nicotine, etc.)? O • 12. Do you have kidney/renal disease, liver disease, or diabetes? O O 13. Do you have any allergies? If so, specify: O O 14, Are you claustrophobic (afraid of enclosed or tight spaces)? O ID 16. Are you wearing a RFID or Radiofrequency ID device (commonly a wristband on an inpatient)? O ID 16. If female, are you (or could you be) pregnant