University Radiology | NJ Imaging Center & Diagnostic Radiology

If yes, where?

If yes, what type of injury, and when did it happen?

If yes, what type of arthritis?

If yes, where?

If yes, where, and what was done?

X-Rays (when and where)?

CT Scans (when and where)?

Bone Scans (when and where)?

MRI Scans (when and where)?

My doctor thinks I have:

Dislocation / Subluxation

Yes No I Don't Know

Labral Tear or Instability

Yes No I Don't Know

Rotator Cuff Tear

Yes No I Don't Know

Impingement

Yes No I Don't Know

My doctor thinks I have:

"Tennis Elbow"

Yes No I Don't Know

Ulnar Nerve Problem

Yes No I Don't Know

Biceps Tendon Problem

Yes No I Don't Know

Are you a pitcher or throwing athlete?

Yes No

My doctor thinks I have:

Carpal Tunnel Syndrome

Yes No I Don't Know

Ligament or Tendon Tear

Yes No I Don't Know

Ganglion Cyst

Yes No I Don't Know

My doctor thinks I have:

Avascular Necrosis

Yes No I Don't Know

Labral Tear

Yes No I Don't Know

My doctor thinks I have:

Meniscal Tear

Yes No I Don't Know

Ligament Tear

Yes No I Don't Know

My doctor thinks I have:

Poor Circulation

Yes No I Don't Know

Achilles Problem

Yes No I Don't Know

Plantar Fasciitis

Yes No I Don't Know

Skin Ulcers

Yes No I Don't Know

Patient Questionnaire For MRI / CT - MSK

Your Area of Concern

My doctor thinks I have:

My doctor thinks I have:

My doctor thinks I have:

My doctor thinks I have:

My doctor thinks I have:

My doctor thinks I have: