Full Name
D.O.B
Have you or have you ever had a pacemaker?
Do you have an artificial heart valve?
Have you ever had any operations on your heart?
Have you ever had any operations on your aorta?
Has the patient ever had operations on the brain?
Do you have any ear implants?
Have you ever had metal fragments in your eyes?
Was it removed?
Do you have any other metal implants in your body?
Have you had surgery in the last 3 months?
Have you ever suffered a shrapnel/ bullet injury?
Do you suffer from renal or kidney problems?
Do you suffer from diabetes?
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