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PERIPHERAL ANGIOGRAM (RUNOFF)
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MRI QUESTIONNAIRE
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PATIENTS NAME:
Date:
DOB:
Age:
SEX:
DIAGNOSIS (Why are you having this study?)
PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)
Claudication (leg pain with walking/exercise)
Leg pain at rest
Non-healing leg wounds or ulcers
Ischemic toes (dark or black toes)
Amputation (please specify)
High blood pressure (hypertension)
How long have you had hypertension?
Are you taking blood pressure medications?
If yes, list your medications:
Smoking
How many packs per day?
How many years have you smoked?
Vascular angioplasty (If so, please describe)
Vascular surgery? (If so, please describe)
Other medical conditions?
PRIOR STUDIES AND INTERVENTION:
Prior MRI (when?)
(Where?)
Angiogram (when?)
Ultrasound (when?)
Non-invasive vascular study (when?)