1. Please describe in detail why your doctor has requested an MRI? ____________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please indicate your symptoms in the diagram:
2. List other imaging (Cat Scans, Ultrasound, X-ray) related to today’s examination with date and location?
____________________________________________________________________________________
3. Do you have Tumor: NO_____ YES_____ Location:_________
Cancer NO_____ YES_____ Year Diagnosed:_______
High blood pressure: NO_____ YES_____
Stroke: NO_____ YES_____
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