Name DEE FEN epsrenl Date of Birth: Jan) SC, SS Height: 5'11"_ weigne_| FS octet Soourty «i Some of the following items may be hazardous to your safety or can interfere with you MRUMRA examination. Please check YES or NO for each of the following items. Have you ever had an accident that required metal fragments to be removed from your eye? . Do you have chest pain? Yes / No If yes: Is it substemal? Yes / No Is it brought on by exertion or emotional stress? Yes / No is it relieved by rest or nitroglycerine? Yes / No Date; Axl \Raor’ EFTA00313928