Screening Questionnaire
This questionnaire will assess your eligibility for participating in an MRI scanning study.
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How did you find out about the study? *
Email address: *
1. Do you have a pacemaker or heart valve (or have you had a pacemaker)? *
2. Do use an insulin or infusion pump? *
3. Do you have brain clip, aortic clip or neurostimulators? *
4. Do you have a stent, coil or catheter? *
5. Do you have metal mesh implants/clips/wire sutures? *
6. Do you have medicated skin patches? *
(some patches contain foil and may cause heating or the magnetic field might modify the dosage)
7. Do you have a hearing aid/implant? *
8. Do you have a glass eye? *
9. Do you have a joint replacement? *
10. Do you have a bullet/shrapnel wound? *
11. Do you have any metal fragment in your body (i.e. eyes, head or skin)? *
12. Do you have an artificial limb? *
13. Have you ever done any metal work or grinding (have you always worn safety goggles)? *
14. Do you suffer claustrophobia? *
15. Could you be pregnant? *
16. Do you have an IUD? *
17. Do you have fractured bones treated with metal? *
18. Have you had any surgery? *
If yes, a) what kind of surgery, b) when, c) what part of the body and d) was there any metal involved.  
19.  Do you have a Shunt, spinal or ventricular? *
20.  Do you wear braces, a retainer, dentures or have a dental bridge? *
If yes, please specify
21. Do you have a tattoo? *
If yes, please specify, a) when and where (country) you had it done? b) Where on the body.
22. Do you have a history of kidney disease/disorder? *
23. Do you have Asthma? *
24. What is your weight? *
25. What is your height? *
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