Ned T. Sahin

Screening Form for Experiment Participation

** fMRI & MEG Experiments **

I. Required Biographical Information

This Information is required in order to process this screening form. All information is kept private at all times according to regulations set forth in the Health Insurance Privacy and Portability Act (HIPPA).



II. MRI Screening Questions

Please carefully note any of the following that apply to you. Explain at right if yes:

No Yes: Description if you answered "Yes":
History of Head Trauma
Surgical Aneurysm Clips
Cardiac Pacemaker
Prosthetic Heart Valve
Implanted Pumps
Previous Surgery
Metal Rods, Plates, Screws
Cochlear Implants
Meniere’s Disease (Inner ear disease causing vertigo)
Hearing Aid
Injury to eyes, or any reason metallic pieces or dust could be in eyes
Breast Feeding
IUD (Intra-Uterine Device)
Tattoos (some have metallic dyes)