Cervical Spine MRI Questionnaire Home > Forms > Cervical Spine MRI Questionnaire Name *DOB *Referring PhysicianPlease answer all questions as best as possible1. How long have you had this problem with your neck?2. Where is your neck pain?3. Do you have headaches?YesNo4. Do you have pain or weakness in any of these?A. Left ArmYesNoB. Right ArmYesNoC. FingersYesNo5. Have you had prior neck surgery?YesNoWhen was the surgery performed?6. Have you had any recent accidents, injuries, or traumas?YesNoPlease give us a brief description of the incident, if applicable.7. If this pain was not due to injury, was the condition gradual?YesNo8. Have there been any other imaging studies of the neck?NoMRICT ScanX-RayWhen and where were the studies perform?Submit