Click here to print this page

KIDNEY / RENAL ARTERY

*Fill out before printing

MRI QUESTIONNAIRE

No information is transmitted
or retained with this form.
 

Close Window

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:)
 

Abdominal Pain

   Abnormal renal function tests  
 

Weight loss (how much?)

If yes, what is your creatinine?

 

Blood in urine test

   Kidney disease (what type?)  
 

Visible blood in urine

  
 

History of cancer (what type?)
 

Kidney tumor or mass (what type?)
 

If yes, have you had any treatment?

 Yes No
 
 

Surgery

 Right Left
   

Partial nephrectomy

 Complete nephrectomy
 
Chemotherapy    

Other Treatment (what type?)
 
 
High blood pressure (Hypertension)    (What is your blood pressure?
 
 

How long have you had hypertension?
 
 

Are you taking blood pressure medications?

 Yes No
 
 

If yes, list your medications:
 
 

Have you had surgery or angioplasty for your renal arteries?

 Yes No
 
 

If yes, do you have a stent placement?

 Yes No
 

Bladder problems (What type?)
 

Other medical conditions?  If yes, please describe:
 
 

PRIOR STUDIES AND INTERVENTION:
 

Prior MRI (when?)

(Where?)
 

Ultrasound (when?)

(Where?)
 

CT (CAT) Scan (when?)

(Where?)
 

Nuclear medicine scan (when?)

(Where?)
 

Angiogram (when?)

(Where?)
 

Biopsy (when?)

(Results?)
 

Surgery (type?)

(When?)
 

Cystoscopy (when?)

(Where?)
 

Other studies and interventions:
 
 
Click here to print this page