1. Please describe in detail why your doctor has requested an MRI? ____________________________________________________________________________________

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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?

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3. Do you have Tumor: NO_____ YES_____ Location:_________

Cancer NO_____ YES_____ Year Diagnosed:_______

High blood pressure: NO_____ YES_____

Stroke: NO_____ YES_____