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PELVIS / HIP 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?
Do you have hip pain?
If yes,
Did you have an injury?
If yes, date of injury:
What movement makes the pain worse?
PRIOR STUDIES AND INTERVENTION:
Prior MRI (when?)
(Where?)
X-Ray (when?)
Are you taking or have you taken anticoagulant medication?
Are you taking or have you taken steroid medication?
What other medications are you currently taking?