SAFETY CHECKLIST

Name *

Last Name *

Date of birth *

Phone *

Address *

Postal code *

City *

Email *

Enter your biological sex *

Which best describes your primary reason for your whole body MRI? *

Please elaborate on the reason for your visit. This lets us know if there are any specific concerns you would like reviewed

PATIENT INFO

Enter your height *

Cm

Enter your weight *

Kg

Do you have any allergies? *

If yes, please list them down

Were you operated for the heart for a cardiac valve or cardiac battery? *

Did you undergo an operation of the brain? *

Did you ever get metal shards, even long ago, in particular near eyes? *

Have you ever had a biopsy? *

Do you have epilepsy? *

Are you claustrophobic or do you suspect you might be claustrophobic? *

Will you take an oral sedative for your scan? *

Have you ever had spinal surgery where you may have received an implant? *

Do you have any orthopedic prosthetics? *

FOR WOMEN ONLY

Are you pregnant or possibly pregnant?

PLEASE TELL US ABOUT YOUR HABITS

Have you ever smoked cigarettes? *

Do you drink alcohol? *

Family & Personal history *

A note about family and personal history:
Although family genes are something you cannot change, attempting prevention or an early control along with changing unhealthy habits can help you avoid a whole lot of unwanted complications or problems. Everyone’s family or personal history of disease is different; but knowing about it could help us analyze and understand the outcomes of the MRI scan better.

Do you or any close member of your family suffer from a neurological pathology? *

Tell us more about the condition

Have you or any close member of your family been diagnosed with cancer? *

Tell us more about the diagnosis

Have you or any close member of your family been diagnosed with a respiratory condition?(e.g. Asthma, Pneumonia, Tuberculosis etc…) *

Tell us more

Have you or any close member of your family been diagnosed with a cardiovascular condition?(e.g. Arrythmia, Heart attack, Abdominal Aortic Aneurysm) *

Tell us more

Have you or any close member of your family been diagnosed with a abdominal condition?(e.g. Hepatitis, Kidney infection, Celiac disease, Pancreatitis etc…) *

Tell us more

How did you hear about Revoscan: *