University Radiology | NJ Imaging Center & Diagnostic Radiology

CT Scans (when and where):

MRI Scans (when and where):

Please describe:

Do you have:

Nausea / Vomiting?

Yes No

Dizziness?

Yes No

Seizures?

Yes No

Visual trouble other than glasses, cataracts?

Yes No

Headaches?

Yes No

Trouble with balance or coordination?

Yes No

Difficulty Walking?

Yes No

Hearing Loss?

Yes No Both Ears

Bell's Palsy?

Yes No

Do you have:

Pain?

No R L Both

Clicking?

No R L Both

Locking?

No R L Both

Trauma?

No R L Both

Fracture?

No R L Both

Surgery?

No R L Both

Injections?

No R L Both

Do you have:

Dizziness?

Yes No

Headaches?

Yes No

Difficulty Walking?

Yes No

Bowel / Bladder Problems?

Yes No

Indicate where you have pain, weakness, numbness, tingling:

Shoulder?

No Pain R L Both

Upper Arm?

No Pain R L Both

Forearm?

No Pain R L Both

Hand?

No Pain R L Both

Thumb / Index Finger?

No Pain R L Both

Middle Finger?

No Pain R L Both

Ring Finger / Little Finger?

No Pain R L Both

Do you have:

Back Pain?

Yes No

Pain in your Legs?

No Pain R L Both

Patient Questionnaire For MRI / CT - Neuro

Your Area of Concern

Do you have:

Do you have:

Do you have:

Indicate where you have pain, weakness, numbness, tingling:

Do you have:

Indicate where you have pain, weakness, numbness: