Allergies: No known drug allergies Latex Allergy: Yes No Complications with □ □ □ anesthesia Yes No □ □ Medication Name and Reaction History Are you claustrophobic? Yes No Have you ever worked with metal (welded)? Yes No □ □ □ □ Do you have metal in your body? Yes No Are you/could you be pregnant? Yes No □ □ □ □ Do you have a: Pacemaker Defibrillator Replacement Heart Valve Vena Cava Umbrella □ □ □ □ Implanted Pump Aneurysm Clip Neurostimulator Metal Plate Other □ □ □ □ □ Social History I live: Alone With: □ □ I live in a: House Apartment Assisted living Nursing home □ □ □ □ Are you a cigarette smoker? Yes, current for year(s) Never Former, quit: □ □ □ If you answered yes, how much did you smoke? Less than ½ pack ½ pack ¾ pack 1 pack □ □ □ □ More (How much? ) □ Do you drink alcoholic beverages? (Check one) None 0-3/month 1-2/week 1-2/day 3-5/day More than 5/day □ □ □ □ □ □ Have you ever had a problem with dependence? Yes No □ □ If yes, what was the dependence and for how long? Are their law suits pending or contemplated related to this condition? Yes No If yes, please provide the □ □ attorney’s name and contact number: Please write any additional information that you feel is important for us to know.
Allergies: □ No known drug allergies Latex Allergy: □ Yes □ No Complications with anesthesia □ Yes □ No Medication Name and Reaction History Are you claustrophobic? □ Yes □ No Have you ever worked with metal (welded)? □ Yes □ No Do you have metal in your body? □ Yes □ No Are you/could you be pregnant? □ Yes □ No Do you have a: □ Pacemaker □ Defibrillator □ Replacement Heart Valve □ Vena Cava Umbrella □ Implanted Pump □ Aneurysm Clip □ Neurostimulator □ Metal Plate □ Other Social History I live: □ Alone □ With: I live in a: □ House □ Apartment □ Assisted living □ Nursing home Are you a cigarette smoker? □ Yes, current for year(s) □ Never □ Former, quit: If you answered yes, how much did you smoke? □ Less than ½ pack □ ½ pack □ ¾ pack □ 1 pack □ More (How much? ) Do you drink alcoholic beverages? (Check one) □ None □ 0-3/month □ 1-2/week □ 1-2/day □ 3-5/day □ More than 5/day Have you ever had a problem with dependence? □ Yes □ No If yes, what was the dependence and for how long? Are their law suits pending or contemplated related to this condition? □ Yes □ No If yes, please provide the attorney’s name and contact number: Please write any additional information that you feel is important for us to know.
Patient-Paperwork.docx