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YOUR VISIT >
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Patient Questionnaire For MRI / CT - Neuro
Patient Name
D.O.B.
Date of Exam
Why is your doctor ordering this exam?
What are your symptoms, and where are they located?
Have you had prior studies for this concern?
Yes
No
CT Scans (when and where):
MRI Scans (when and where):
Do you have a known Neurologic condition?
Yes
No
Please describe:
Is today's study to evaluate this condition?
Yes
No
Have you had neck or back surgery?
Yes
No
Please describe:
Your Area of Concern
Brain or MRA / Carotid
TMJ
Cervical / Thoracic Spine
Lumbar Spine
Do you have:
Nausea / Vomiting?
Yes
No
Dizziness?
Yes
No
Seizures?
Yes
No
Visual trouble other than glasses, cataracts?
Yes
No
Please describe:
Headaches?
Yes
No
Please describe location and character:
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
Please describe:
Pain in your Legs?
No Pain
R
L
Both
Indicate where you have pain, weakness, numbness:
Thigh?
No Pain
Front
Back
Inside
Outside
Lower Leg?
No Pain
Front
Back
Inside
Outside
Foot?
No Pain
Front
Back
Inside
Outside