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: ________________