Please contact your physician if you can answer �yes� to any of the following questions:

DO YOU CURRENTLY, OR HAVE YOU EVER HAD:

	Yes	No
1. Pacemaker	_____	_____
2. Brain surgery	_____	_____
3. Aneurysm clips	_____	_____
4. Neurostimulator	_____	_____
5. Foreign body in eye (metal from welding/grinding).	_____	_____
6. Middle ear prosthesis (Cochlear implant/ear surgery)	_____	_____
7. Claustrophobia	_____	_____
8. Implanted electrical devices	_____	_____
9. War injury or gunshot wound	_____	_____
10. Orbit prosthesis/eye surgery	_____	_____
11. Prosthetic heart valve	_____	_____
12. Heart surgery	_____	_____
13. Known or possible pregnancy/breast feeding	_____	_____
14. IUD	_____	_____
15. Dentures	_____	_____
16. Latex/tape sensitivity	_____	_____