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AORTOGRAM (AORTIC ARCH/AAA)
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MRI QUESTIONNAIRE
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PATIENTS NAME:
Date:
DOB:
Age:
SEX:
DIAGNOSIS (Why are you having this study?)
PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)
Chest Pain
Abdominal pain
Stroke/TIA
Lightheadedness
High blood pressure (hypertension)
Shortness of breath
What is your blood pressure?
How long have you had hypertension?
Are you taking blood pressure medications?
If yes, list your medications:
Smoking
How many packs per day?
How many years have you smoked?
Connective tissue disorder (please specify)
Aortic aneurysm
Aortic dissection
Aortic surgery? (If so, please describe)
Other medical conditions?
PRIOR STUDIES AND INTERVENTION:
Prior MRI (when?)
(Where?)
Echocardiogram (when?)
CT (CAT) Scan (when?)
Ultrasound (when?)
Angiogram (when?)