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FEMALE PELVIS MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

DOB:

Age:

SEX:

 M F

DIAGNOSIS (Why are you having this study?)

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

Are you having regular menstrual periods?

 Yes No

Are you having abnormal menstrual periods?

 Yes No

If yes, please describe:
 
 

When was the first day of your last menstrual period?
 

Are you taking oral contraceptives?

 Yes No
 

Are you taking hormone replacement therapy?

 Yes No
 

Are you taking Tamoxifen?

 Yes No
 

Pregnancies

 Yes No
 

If yes, how many?

 How many deliveries?
 

Have you had a Cesarean section (C-section)?

 Yes No
 

Fibroids

 Yes No
  If yes, have you received any treatment Yes No
 

Please describe:
  Pelvic masses or tumors? Yes No
 

If yes, what type?
 

Have you received any treatment?

 Yes No
 

Please describe:
  Other pelvic conditions? Yes No
 

If yes, please describe:
 

History of cancer (what type?)?
 

Other medical conditions?
 

PRIOR STUDIES AND INTERVENTION:
 

Prior MRI (when?)

(Where?)
 

Ultrasound (when?)

(Where?)
 

CT (CAT) Scan (when?)

(Where?)
 

Biopsy (when?)

(Results?)
 

Hysterosalpingogram (when?)

(Results?)
 

Laparoscopy (when?)

(Results?)
 

Laparoscopy (type?)

(Where?)
 

Other studies and interventions:
 
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