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WRIST 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 an injury to your wrist?
If yes, how and when?
Do you feel a snap when moving the wrist?
Do you hear a click in the wrist?
Describe the one particular movement of the wrist which makes your complaints worse:
Did you have this wrist in a cast?
If yes, when?
Do you participate in sports?
If yes, specify which one and level of participation?
PRIOR STUDIES AND INTERVENTION:
Prior MRI (when?)
(Where?)
X-Ray (when?)
Surgery (when?)