Al MRI Patient Questionnaire Name: Birth Date: Primary physician: Surgeon: Next appointment with your physician or surgeon? PATIENT HISTORY Yes No Yes No Yes No Yes No Has anyone in your family ever had breast or ovarian cancer? Mother Sister Daughter Aunt Grandmother Have you taken or are you currently taking hormone replacements or birth control pills? If yes, type: When did you stop? Do you have breast implants? Are you Curre.
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How to fill out the OHSU MRI Breast Imaging Patient Questionnaire online
Completing the OHSU MRI Breast Imaging Patient Questionnaire is a crucial step in your diagnostic imaging process. This guide will help you navigate the online form efficiently and effectively, ensuring that all necessary information is submitted accurately.
Follow the steps to successfully complete the questionnaire online.
- Click ‘Get Form’ button to access the document in your preferred editor.
- Begin filling out your personal information. Enter your name and birth date in the appropriate fields.
- List your primary physician and surgeon by filling in their names in the specified sections.
- Indicate the date of your next appointment with your physician or surgeon by using the format provided.
- Respond to the patient history questions by selecting 'Yes' or 'No' where applicable. Make sure to provide additional details, such as family history of breast or ovarian cancer, and whether you are currently taking any hormone replacements or birth control pills.
- Under previous biopsies or surgery, indicate any relevant procedures that apply to you by marking the appropriate checkboxes for each side of your body.
- For the reason for the exam section, select all applicable options and provide details as needed.
- Mark the location of any breast lumps or previous surgeries clearly, ensuring you specify the side of the body.
- Sign and date the form where indicated, and clarify your relationship to the patient.
- After completing the form, check your entries for accuracy, then save your changes, download a copy for your records, or share the completed form as necessary.
Complete the OHSU MRI Breast Imaging Patient Questionnaire online today to ensure a smooth diagnostic process.
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