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CERVICAL SPINE MRI QUESTIONNAIRE

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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 have neck pain?

 Yes No

Do you have difficulty walking?

 Yes No

Do you have leg pain?

 Right Left
     
Do you have pain, numbness or weakness in any of the following areas?

Upper arm?

 Right Left (C5)

Elbow?

 Right Left (C6)

Lower arm?

 Right Left (C7)

Hands & Fingers?

 Right Left (C8 - T1)

Have you had previous significant spine injury?

 Yes No

If yes, describe:
 

PRIOR STUDIES AND INTERVENTION:
 

Prior MRI (when?)

(Where?)
 

CT (CAT) (when?)

(Where?)
 

Spine injury (when?)

(Where?)
 

Myelogram (when?)

(Where?)
 

Other studies and interventions?

    
 
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