Name:___________________________Date:______________D.O.B._____________(MM/DD/YY)
SUBJECT INFORMATION SHEET
1. Do you have a problem with claustrophobia (fear of closed spaces)?No____ A little___ Pretty much_____ Severe _______
2. Do you have a heart pacemaker or defibrillator? No___ Yes___
3. Have you ever had an operation? No___ Yes ___
4. Have you ever been injured by a metallic foreign body which was not removed? No___ Yes ___
5. Do you wear braces on your teeth, or do you have false teeth or removable bridgework?
No___ Yes ___
6. (Females Only): Is there any possibility that you are pregnant? No___ Yes ___
7. Please list medications your physician has prescribed for you to take.
(Try to include the name of the medicine, dose, how often, and time of last dose).
SUBJECT SIGNATURE_________________________________________DATE: ________________