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PROSTATE / MALE PELVIS

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MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

DOB:

Age:

DIAGNOSIS (Why are you having this study?)

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

Pelvic pain

Blood in urine
 

Pain on urination

 Sexual dysfunction
 

Difficulty urinating

  
 

Other symptoms?  Please describe:

    
 

PROSTATE
 

What is your PSA level?
 

Have you had a prostate biopsy?

 Yes No
 

If yes, when?
 

Results?

If you have prostate cancer, have you recently received treatment?

 Yes No
 

If yes, what type?
  Surgery Yes No
 

Radiation

 Yes No
  Radiation seed implants Yes No
  Have you had prostatitis? Yes No
 

SCROTUM / TESTES
 

Do you have a scrotal mass?

 Yes No
 

If yes, which side?

 Right Left
 

Do you have scrotal pain?

 Yes No
 

If yes, which side?

 Right Left
 

Have you had recent trauma?

 Yes No
 

If yes, which side?

 Right Left

Have you had  infection or inflammation in your scrotum?

 Yes No
 

If yes, which side?

 Right Left

Any other relevant symptoms?  Please describe:

PRIOR STUDIES AND INTERVENTION:
         
 

Prior MRI (when?)

(Where?)
 

Ultrasound (when?)

(Where?)
  CT (CAT) Scan (when?)

(Where?)
 

Bone scan (when?)

(Results?)
 

Other studies and interventions:
 

 
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