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HEAD MRI / MRA 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?
Do you have weakness on one side of your body?
If yes, which side?
PRIOR STUDIES AND INTERVENTION:
Prior MRI (when?)
(Where?)
CT (CAT) Scan (when?)
Head Surgery (when?)
Chemotherapy (when?)
Radiation Therapy (when?)
Other studies and interventions?