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The document consists of questionnaires for patients undergoing MRI examinations of the brain, spine, and neck. It collects personal information, previous medical history, and specific symptoms related to neurological and spinal health. The aim is to assist healthcare providers in planning and interpreting the MRI exams effectively.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name and sex in the designated fields at the top of the form.
Indicate if you have had a previous CT or MRI examination of the brain or spine by selecting 'Yes' or 'No'. If 'Yes', provide details on when and where it was conducted.
For each symptom listed, such as changes in memory or headaches, select 'Yes' or 'No'. If applicable, specify right or left side for certain symptoms.
Complete additional questions regarding past medical history, including strokes, seizures, and surgeries. Provide specific details where prompted.
If applicable, shade areas on the provided diagrams to indicate pain or numbness locations.
Review all entries for accuracy before submitting your completed form.

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