Cervical And or Thoracic Spine

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					                                    MRI Cervical And/or Thoracic Spine

Patient Name: _______________________________________________________________________________________________________________________

Diagnosis/Symptoms: ___________________________________________________________Doctor: _________________________________________

What other studies have you had?  MRI CT            Myelogram        EMG      X-Rays

         When was the study performed? __________________________________________________________________________

         Where was the study performed? _________________________________________________________________________

         What were the results? _________________________________________________________________________________

         How has your condition changed since this study? ____________________________________________________________


Do you have neck pain?     No     Yes

         Does the pain travel down your arm?  No Yes        Which arm?         Right Left     Both

                 When did the pain start? ________________________________________________________________________

                 Did the pain start suddenly or gradually? ___________________________________________________________

         Is the pain from an injury or accident?  No Yes

                 If yes- Describe_________________________________________________________________________________

Do you have weakness of an arm or hand?  No         Yes     Which arm / hand?  RightLeft Both

Do you have numbness or tingling of an       No     Yes     Which arm / hand?  RightLeft Both
or hand?

Do you have difficulty walking normal?       No     Yes     Describe: _________________________________________________

Do you have electric like feelings down      No     Yes
your spine?

Have you broken a bone in your neck?         No     Yes     When? ___________________________________________________

                                                              Where in your neck? ________________________________________

Have you had surgery on the bones of         No     Yes     When? ___________________________________________________
your neck?
                                                              What Level? (C4-5, C5-6, etc)_________________________________

                                                              What problems were you having?_____________________________

Have you had any type of cancer?             No     Yes     What type? _______________________________________________

                                                                When was it diagnosed? ____________________________________

                                                              Where was it located? _______________________________________

                                                              What kind of treatment did you have? __________________________

                                                              When was your last treatment? _______________________________

Any other medical problems you are seeing the doctor for? ____________________________________________________________

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