E-Referral Questionnaire

Patient Information
MM slash DD slash YYYY
The patient has confirmed

Study to Be Performed

Whole Body MRI Screening Examination

List All Surgery

Please list all surgery and specify a date and type:
Date of last menstrual cycle
MM slash DD slash YYYY
Height & Weight

For MRI Patients

Yes No
Have you had a previous MRI?
Has metal ever gone into your eye?
Are you claustrophobic?

Do You Have Any of The Following:

Yes No
Aneurysm Clips
Artificial Cardiac Valve
Cardiac Pacemaker
Cochlear Implants
Retained Pacing Wires
For CT Patients (Coronary CTA): Previous reaction to IV contrast
Tobacco Use
Alcohol Use
Recreational Drugs
Do You Exercise Regularly
Contact Now

Get in Touch

In a hurry? Call us at

647-910-2639 info@wholebodymri.ca