Lumbar MRI Questionnaire

Home > Patient Forms > Lumbar MRI Questionnaire

Name *

DOB *

Referring Physician

Please answer all questions as best as possible

1. What are the reasons you are having the examination?

2. How long have you had this pain?

3. Is the pain in the middle of the back?YesNo

4. Does the pain radiate along the:

A. ButtocksLeftRight

B. Front of ThighLeftRight

C. Outer ThighLeftRight

D. Back of ThighLeftRight

E. Front of CalfLeftRight

F. Back of CalfLeftRight

5. Have you had low back surgery?YesNo

When was the surgery performed?

6. Have you had any recent accidents, injuries, or traumas?YesNo

Please give us a brief description of the incident, if applicable.

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

8. Have there been any other imaging studies of the neck?NoMRICT ScanX-Ray

When and where were the studies perform?

Signup our newsletter to get update information, news, insight or promotions.