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Age:
Gender
Current (Prescription) Medications being taken
Prescription medications taken in the past:
Have you ever been diagnosed with any psychiatric or psychological disorders (e.g. Autism spectrum disorder, depression, ADD…)?
Do you currently have braces or other unremovable orthodontia?
Have you had an MRI before?
Do you have any metal in your body (accidental or implanted)?
Is there any possibility that you are currently pregnant?
Are you at all claustrophobic?
Do you have sinus problems?
Have you recently experienced dizziness, loss of balance, or loss of consciousness?
Have you ever worked with metals (welding, grinding, machinist, etc.)?
Please indicate if you currently have, or have ever had, any of the following:
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