Shoulder MRI Questionnaire

Home > Patient Forms > Shoulder MRI Questionnaire

Name

DOB

Referring Physician

Please answer all questions as best as possible

1. Which shoulder are you having examined today?LeftRightBoth

2. What is the reason your doctor prescribed you for an MRI of the shoulder?

3. How long have you had this pain in your shoulder(s)?

4. Is the shoulder painful when your arms are raised over your head?YesNo

How long does the pain last?

5. Have you had surgery on the shoulder?YesNo

When was the surgery performed?

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

When did it occur?

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 your shoulder?NoMRICT ScanX-Ray

When and where were the studies perform?

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