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Generic MRI Form and Patient Survey

Created By JohnY February 2014 - Some time ago, C Sedergreen posted something about yet another MR requisition, this time requiring patient screening questionnaire. I was able to find a good PDF of the screening questions, but not able to get the actual requisition itself. So I’ve modified the existing FHA MRI req (background actually NOT from FHA, it’s mine), and added the essentials to the older form. The screening questionnaire was not designed to submit, as the patient is required to fill it in and bring to MR clinic for review with the technologist at the time of scan. So it’s a print and give eForm. EForm in zip format for easy upload. Comments welcome. JohnY
Generic MRI requisition - V3_Sep25_2017
Updated for Pathways by JohnY. Includes Chrome compatible Drop Down menu as per Dr. Paras Mehta. Requires accompanying Patient Screening Questionnaire
MRI Pt Screening Form
Updated for Pathways, JohnY
Generic MRI Form png image
Generic MRI form zip
This eForm currently does not zip import properly. You can zip for the background upload. But after the HTML loads, it needs to be debugged as follows. Unzip the zip file. Reload the HTML to the saved eForm in edit mode. In V15, you will need to open the HTMl file to source code, and then copy-paste the working HTML. The correction to this zip file is pending. JohnY (Aug13_2017).
Patient survey
to be printed and handed to the patient to fill out and take to the appointment
Pt Screening questionnaire for MRI

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