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LIVER / MRCP / PANCREAS

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MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

DOB:

Age:

SEX:

 M F

DIAGNOSIS (Why are you having this study?)

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

Abdominal Pain

   Abnormal renal function tests  
 
Weight loss (how much?)

Hepatitis? (what type?)
 

Jaundice (yellowing of skin/eyes)

   Cirrhosis  

High alcohol intake in the past

 Other liver disease (what type?)

High alcohol intake currently:

History of cancer (what type?)

Liver tumor or mass (what type?)

Gallstones

 Acute pancreatitis

Gallbladder removal

 Chronic pancreatitis

Bile duct stones

 Complications of pancreatitis (what type?)

Bile duct infection

Sclerosing cholangitis

 Diabetes

Inflammatory bowel disease (what type?)

 Pancreas tumor or mass (what type?)
 

Other medical conditions?  If yes, please describe:
 
 

PRIOR STUDIES AND INTERVENTION:
         
 

Prior MRI (when?)

(Where?)
 

Ultrasound (when?)

(Where?)
 

CT (CAT) Scan (when?)

(Where?)
 

Cholangiogram (ERCP) (when?)

(Where?)
 

Biopsy (when?)

(Results?)
 

Surgery (type?)

(When?)
 

TIPS procedure (when?)

(Where?)
 

Stent placement (when?)

(Where?)
 

Drainage procedure (when?)

(Where?)
 

Other studies and interventions:
 
 
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