Ned T. Sahin

Screening Form for Experiment Participation

This Information is required in order to process this screening form. All information is kept private at all times according to regulations set forth in the Health Insurance Privacy and Portability Act (HIPPA).

Name

Year of Birth

Gender

Height (feet) (inches)

Weight (lbs)

E-Mail Address

Race:

White Asian American Indian / Alaskan Native No Report

Black/African American Pacific Islander More Than One Race

Ethnicity:

Hispanic Not Hispanic No Report

Today's Date

Type of Exam

Principle Investigator

Patient Volunteer

II. MRI Screening Questions

Please carefully note any of the following that apply to you. Explain at right if yes:

No Yes: Description if you answered "Yes":

History of Head Trauma

Surgical Aneurysm Clips

Cardiac Pacemaker

Prosthetic Heart Valve

Neurostimulator

Implanted Pumps

Previous Surgery

Metal Rods, Plates, Screws

Cochlear Implants

Meniere’s Disease (Inner ear disease causing vertigo)

Hearing Aid

Dentures

Injury to eyes, or any reason metallic pieces or dust could be in eyes

Breast Feeding

IUD (Intra-Uterine Device)

Tattoos (some have metallic dyes)

Name
Year of Birth
Gender
Height (feet)		(inches)
Weight (lbs)
E-Mail Address

White	Asian	American Indian / Alaskan Native	No Report
Black/African American	Pacific Islander	More Than One Race

	No	Yes:	Description if you answered "Yes":
History of Head Trauma
Surgical Aneurysm Clips
Cardiac Pacemaker
Prosthetic Heart Valve
Neurostimulator
Implanted Pumps
Previous Surgery
Metal Rods, Plates, Screws
Cochlear Implants
Meniere’s Disease (Inner ear disease causing vertigo)
Hearing Aid
Dentures
Injury to eyes, or any reason metallic pieces or dust could be in eyes
Breast Feeding
IUD (Intra-Uterine Device)
Tattoos (some have metallic dyes)