Brain MRI Questionnaire Home > Forms > Brain MRI Questionnaire Name *DOBReferring PhysicianPlease answer all questions as best as possible.1. What are the reasons your doctor has scheduled you for an examination of the brain?2. Is there any history of dizziness or hearing loss?YesNoWhich side?LeftRightBoth3. Are you being or were you ever treated for medical illness?YesNoPlease specify4. Please list any surgical procedures/operations that you have had.5. Is there a history of weakness and if so, which side?NoLeftRight6. Is there a history of numbness and if so, which side?NoLeftRight7. Have you ever had chemotherapy?YesNoWhen did you receive the treatment?8. Is there any history of seizures?YesNo9. Is there any history of traumas or accidents?YesNoIf so, please give a brief description of the incident.10. If this pain was not due to injury, was the condition gradual?YesNo11. Do you have any problems with respect to memory and forgetfulness?YesNo12. Are you currently taking any medication? If yes, what are you taking?Submit