1. Have you had prior surgery or an operation (e.g. arthroscopy, endoscopy, etc.) of any kind?
No □ Yes □
If yes, please indicate the date and type of surgery below:
Once, I plucked the wings off a ladybug. I thought it loved me, so I pulled out the rice paper
films. They oozed liquid. There was no blood. I was eight. I spent many months as a
murderer surgeon.
2. Have you had a previous Diagnostic Imaging study or examination (MRI, CT, Ultrasound, X-ray, etc.)?
No □ Yes□
If yes, please indicate the date, facility name and address, phone number and body parts.
The first time my breasts lit from the inside, I was forty-two. Cells grew. Spiculated
morningstars swinging inside fat tissue. It was winter. I wore a large red sweater. My hair was
long, coarse like horsehair.
3. Have you experienced any problem related to a previous MRI examination or MR procedure?
No □ Yes□
After the contrast dye moves through and up my left arm, there will be bruises, small spots
of purple and grey veins. The technician asks, “How’re you doin’?” as the tube bursts with
electric sounds, and I’m listening to Miles Davis’s trumpet break through the noise. I think
about the blooming, warm liquid slithering through blood. Does it look blue inside the
body? “Drink a lot of water today,” he says.
4. Have you had an injury to the eye involving a metallic object or fragment (e.g. metallic silver shavings, foreign body, etc.)?
No □ Yes□
If yes, please describe:
Small goblin jellyfish lymph nodes. They also had rogue cells. They gathered at my armpit,
lit up with the contrast dye.
5. Have you ever been injured by a metallic object or foreign body (e.g. BB, Bullet, Shrapnel, etc.)?
No □ Yes□
My father was with me. He was lean with big, long, black werewolf hair and beard. I sat on
the back of the bike and I tried. I really tried. He kept yelling, “Keep your legs wide!” I think
that’s what he said. I do not remember the sounds from his mouth. I remember the spokes
of the wheel bit through brand new school shoes. There was no skin on my right ankle. I
could see right through to the bone, the web of tendons. I thought somewhere inside would
be the answer. My father never stopped yelling.
6. Have you ever worked as a hobbyist or through employment in a metal shop, tool and die shop, or handled power tools involved in cutting or welding metal, or engaged in similar activities using metal?
No □ Yes□
I dream of chainsaws sometimes. They are my arms and I am metal blades and skin. In the
dream, I cut through bricks, tree trunks, walls. Make windows out of silence.
7. Are you currently or have recently taken any medication or drug?
No □ Yes□
I was driving through the Appalachian Mountains. There were goats and other
creatures bouncing around the green wilderness near the highway. Diagnosis = Obesity.
Morbidly obese = BMI > 40. Obese. Obese. The doctor said, take these pills. Take them and
try for hunger. I was driving when my throat started closing up. A tingle on my face, hives
bursting out from freckles. I drove, gasping. Forty miles to the hospital.
8. Are you allergic to any medication?
No □ Yes□
Morbid obesity = BMI > 40. Am I still this equation twenty years later?
9. Have you ever had an allergic reaction to iodine, or any other contrast material or dye used for an MRI or CT examination?
No □ Yes□
“Don’t forget to drink lots of water” is what the technician always says after he helps me out
of the tube, half-naked with no bra or shoes, no glasses so the world is swirled blobs of
things, chairs, gowns, the metal door, the white-tiled floor. My mouth and tongue are dry.
10. Do you have anemia or any disease(s) of the blood, a history of renal (kidney) disease or seizure?
No □ Yes□
What does the contrast dye do to organs?
2016-2020 = 12 MRIs, CT scans, PET scans ≅ how many moments of history I cannot get
back? How many cells I cannot claim?
For female patients:
11. Are you pregnant?
No □ Yes□
When my niece was born, she was an angry angry baby. Five pounds and something. Lungs
like a crazed parrot, she spent her first three months flushed, red with rage. Her body would
seize up tight from the cries out of her small, fish mouth and she would become an
immovable thing, arms raised, legs pulsing back and forth, her whole face blotted with
blood. She seethed. I think she was not fully cooked. I think she knew about this raw deal of
life beyond her mother’s womb.
12. When was your last menstrual cycle?
My oncologist said “Medically-induced menopause. The goal is to shrivel your ovaries.”
Desiccated. Like dried up grapes. I hate raisins. They taste of sun after it’s stopped loving
bodies, skin. An enraged sun and then poof, grooved skin sucked empty.
Note: the questions are adapted and revised from the standard questionnaire from Diagnostic Medical Imagining
*This poem won First Place in the SWWIM For-the-Fun-of-It Contest.