Rayson Radiology Center

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	ANKLE / FOOT MRI QUESTIONNAIRE	No information is transmitted or retained with this form.
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PATIENTS NAME:		Date:

DIAGNOSIS (What complaints or symptoms caused you to seek medical help?)

PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)

How long have you had these symptoms?

Did they develop suddenly or gradually?	Suddenly	Gradually
Do you hear a click in your ankle?	Yes	No
Do you have pain when walking?	Yes	No
Do you have pain when jumping?	Yes	No
Do you have pain when twisting your foot inward?	Yes	No
Do you have pain when twisting your foot outward?	Yes	No
Do you participate in sports?	Yes	No

If yes, specify which one(s) and to what level:

PRIOR STUDIES AND INTERVENTION: