MRI Breast Imaging Patient Questionnaire - OHSU 2026

1. Click ‘Get Form’ to open the MRI Breast Imaging Patient Questionnaire in our editor.
2. Begin by entering your personal information at the top of the form, including your name, birth date, primary physician, and surgeon. This section is crucial for identifying your medical history.
3. In the 'Patient History' section, answer the questions regarding family history of breast or ovarian cancer and any hormone replacements or birth control pills you may have taken. Use the checkboxes to indicate your responses.
4. Proceed to the 'Previous Biopsies or Surgery' section. Indicate any past procedures by checking the appropriate boxes for each type of biopsy or surgery you have undergone.
5. In the 'Reason for Exam' section, check all applicable reasons for your MRI exam. This helps healthcare providers understand your needs better.
6. Mark any locations of breast lumps or surgeries on the diagram provided. This visual aid is important for accurate assessment.
7. Finally, sign and date the form at the bottom. Indicate your relationship to the patient if applicable.

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