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Evious Coronary Angiogram/ECHO/SPECT Date Nr/Findings: Postcode : D.O.B: Sex: Tel No: MRI Contra -indica ons - does the pa ent have: A cardiac pacemaker? Yes No Is the pa ent diabe c? Yes No A history of neurosurgery? Yes No Is there a cross-infec on risk? (eg MRSA) Yes No A neuros mulator? Yes No Can the pa ent breath-hold? Yes No Programmable hydrocephalus shunt? Yes No Does the pa ent have renal impairment? Yes No Metallic foreign body in the eye (ever)? Ye.

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