Rayson Radiology Center

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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?	Suddenly	Gradually
Do your legs or back hurt after you walk?	Yes	No
Do you have weakness in your legs?	Yes	No

Do you have pain, numbness or weakness in any of the following areas?

	Back	Right	Left
	Buttocks	Right	Left (S1)
	Front of Thigh	Right	Left (L1-L2)
	Back of Thigh	Right	Left (L5-S1)
	Front near big toe	Right	Left (L5)
	Front near small toe	Right	Left (S1)
	Do you have a history of cancer?	Yes	No

Have you had previous significant spine injury or injection?		Yes	No

If yes, please describe:

PRIOR STUDIES AND INTERVENTION:

	Prior MRI (when?)		(Where?)
	CT (CAT) scan (when?)		(Where?)
	Spine Surgery (when?)		(Where?)
	Myelogram (when?)		(Where?)
	Other studies or interventions?