ed? If yes, when? Any surgery on your eyes, ears brain or heart? DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? Brain/Aneurysm Clips Pacemaker, Pacer Wires or Defibrillator if yes, make\ year Ear Implants or Hearing Aids Electrical Stimulators Implant/Prosthesis Infusion Pumps Coils. Catheters. Fitters or Wires in

scopy within the last 6 weeks? If yes. date of exam YES NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? 0 Brain/Aneurysm Clips 0 Pacemaker, Pacer Wires or Defibrillator if yes. make% year O Any Metallic fragment or foreign body O Ear Implants or Hearing Aids O Electrical Stimulators O Implant/Prosthesis O

within the last 6 weeks? If yes, date of exam YES NO DO YOU HAVE ANY OF THE FOLLOWING IN YOUR BODY? 0 0 Brain/Aneurysm Clips 0 0 Pacemaker, Pacer Wires or Defibrillator if yes, make\ year 0 0 Any Metallic fragment or foreign body CI O Ear Implants or Hearing Aids 0 C7 Electrical Stimulators 0 0 Implant/Pr