Confidential Questionnaire For Patients

Please complete the below electronic form before your visit us, to help us assess your injury or issue and speed up the process. Alternatively, if you’d prefer not to complete the electronic form, you can download the form here, complete it and then either fax the form to us on (03) 9593 1876, or scan and email the form to info@baysidestandingmri.com.au. If you have trouble completing the form, contact us and we’ll be happy to go through it with you.
NOTE: Before starting the form, choose your screen rotation (if using a tablet or mobile) and click on the refresh button below. This will ensure our special body discomfort-point tool can be correctly configured.

YOUR DETAILS

(CONFIDENTIAL - YOUR PRIVATE INFORMATION IS USED ONLY BY US TO HELP YOU)

Full Name (required)

Street Address and Number (required)

Suburb (required)

Postcode (required)

Home Phone

Mobile Phone

Work Phone

Your Email (required)

Birth Date (dd/mm/yyyy - required)

Height in cms (required)

Weight in kgs (required)

Occupation

How Did You Find Out About Our Services

Have You Ever Had An MRI Before

If you have had an MRI before, please provide details on when and why

SAFETY CHECK

Please note here if you have any of the following (if you are unsure, do not hesitate to ask one of the staff at Bayside MRI)

Cochlear implant or Neurostimulator

An inserted pump device

A programmable, magnetically adjustable ventriculoperitoneal shunt

Pacemaker or Defibrillator

Any tattoos

Any piercings

Had surgery in the past 6 weeks

If you checked any of the above items, please elaborate here

WHERE IS THE PROBLEM

Please take a look at the diagrams below this form and click on the areas that are causing you discomfort or concern. If you make a mistake, simply click again to undo. You can select multiple areas if necessary.

Right, Side
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Back
 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82

Front
 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79

Left, Side
 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

FINANCIAL

I understand that this is a private MRI service and that this office does not hold accounts. In the event that there is an unpaid account, I will be liable for any administration costs charged to me. I agree that all services rendered to me are charged directly to me (No Medicare Rebate applies) and that I am personally responsible for payment.

Your Name (required)

Please indicate your acceptance of these financial terms by ensuring the box below is checked (required)

Today's Date (required)

YOUR MAJOR COMPLAINT

Please let us know the reason that an MRI is required.

Describe your main problem or symptoms

When and how did is start (include approximate date started and duration)

Was there any of the following prior to or during the onset
 Illness / infection Trauma Other significant event

Is your problem
 Getting worse Not changing Improving

Is the pain
 Constantly there Intermittent - on and off

Describe what makes your symptoms worse

Describe what relieves your symptoms

Are your symptoms worse at night or any specific time of the day

Do you get pain travelling down into your arms or legs

if you answered yes to the previous question, please provide further details here

Does your current pain involve any of the following?

Tingling in either arm or leg

if yes, describe where

Numbness in either arm or leg

if yes, describe where

Weakness in either arm or leg

if yes, describe where

'Weird' sensations in either arm or leg

if yes, describe where

Have you seen anyone else for this current condition?

if yes, please list their names

Have you ever had this problem before?

If yes, please describe, including how often

Are you currently taking any medication, substances, vitamins, supplements, herbs?

If yes, please list all items you are currently taking including the item's name and the reason you are taking it

You have now completed your questionnaire. Please submit the details you have provided us by clicking on the button below.