LJ EAST RIVER MEDICAL IMAGING. PC MAGNETIC RESONANCE IMAGING (MRI) Patient Name: EPSTEIN, JEFFREY MRN #. 0315152 Exam Code: MRCLAVL Age: 65 Years Sex: M Height: Feet Inches Weight. Ibs Exam Date: 06/05/2018 Referring Physician: MOSKOWITZ, BRUCE W. M.D. M.D. Acc# 7156124 ee IMPORTANT: Please notify the receptionist if you answer "YES" to any of the questions below. The receptionist will inform the technologist/radiologist of your response. PLEASE CHECK: Have you had metal removed from your eyes? Have vou been shot with bullets, BB's or shrapnel? Are you pregnant? Are you nursing? Are you on hemodialysis or peritoneal dialysis? Do you require oxygen or an inhaler? Do you have renal disease? if yes please describe Are you wearing any metallic items? Any surgery on the area to be imaged? If yes, when? Any surgery on your eyes, ears brain or heart? Have you had a Colonoscopy and/or Endoscopy within the last 6 weeks? if yes, date ofexam 0 NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? Brain/Aneurysm Clips Pacemaker, Pacer Wires or Defibrillator if yes, make\ year Any Metallic fragment or foreign body Ear Implants or Hearing Aids Electrical Stimulators Implant/Prosthesis Infusion Pumps Coils. Catheters. Filters or Wires in blood ° Artifical Limbs or Joint Replacement Tattooed Eveliner Artificial Heart Valves Stents If yes, please provide date of implant: Maanetic Dental Implants aia Patches Tissue expander for future implants ooo0o000co0nR Bone Stimulators. Insulin Pumps. or Mechanical Valves Programmable Shunts ooooo0000000000000 § Technologist's Use Only Patient Complaint/Diagnosis: Any previous imaging studies in this area? yes O NO If yes, where? Technologist: Wet Reading EC) YES C2 NO Dr's Phone Number: SECTS MRI Questionnaire 09-2013 $000/t000B Ivd KV TZ:8 STOzZ/o0C/s0 EFTA00313968