Extremity MRI Questionnaire

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Name

DOB

Referring Physician

Please answer all questions as best as possible

1. Which extremity is being studied today? (Please select all that apply)HipWristThighForearmLower LegElbowAnkleHandFootJaw

2. On which side of the body?LeftRight

3. Please select all symptoms or complaints you have.PainFluid in JointMassRednessSwellingLockingClickingLimited Movement

4. How long have you had these symptoms/complaints?

5. Have you undergone any therapy?(i.e. physical therapy, bed rest, etc.)YesNo

Type of therapy

Duration

Outcome

6. Please give us a brief history of how the injury occurred if applicable.

7. If this pain was not due to injury, was the condition gradual?YesNo

8. Have there been any other studies on the affected area?NoMRICT ScanX-RayUltrasound

Where and when were the studies performed?

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