Click here to print this page

 

*Fill out before printing

SHOULDER MRI QUESTIONNAIRE

No information is transmitted
or retained with this form.
 

Close Window
 

PATIENTS NAME:

Date:

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

Dominant arm?

 Right Left

Involved arm?

 Right Left

Do you have painful restriction of motion?

 Yes No

Do you have tightness?

 Yes No

Do you have pain?

 Yes No

If yes, describe location, severity and time:

Did you have an injury?

 Yes No
 

If yes, date of injury:

Age at onset of injury:
 

Type of injury

Onset of present condition and duration?

Do you participate in sports?

 Yes No
 

If yes, specify sport and level of participation:
 

PRIOR STUDIES AND INTERVENTION:
 
 

Prior MRI (when?)

(Where?)
 

X-Ray (when?)

(Where?)
 

Surgery (when?)

(Where?)
 

Other studies and interventions:
 
 
Click here to print this page