Trinitas Diagnostic Imaging
415 Morris Avenue, Elizabeth, NJ 07208
908-351-7600 (Phone) | 908-351-4406 (Fax)
www.TrinitasDiagnosticImaging.com

If you're coming to our center for this test, print this page, fill out the form and bring it in with you on the day of your appointment.

 

FIRST NAME
LAST NAME
AGE

WEIGHT   DATE  
WHAT WAS YOUR CHIEF COMPLAINT WHEN YOU VISITED YOUR DOCTOR?





WHAT DO YOU THINK CAUSED THE PROBLEM?





DOES YOUR PAIN GO DOWN YOUR LEG?
YES   NO
(IF YES, WHICH?):




DO YOU HAVE ANY NUMBNESS OR WEAKNESS?
YES   NO
(IF YES, WHERE?):




HAVE YOU HAD SPINE SURGERY ?
YES   NO
(IF YES, WHEN AND WHAT WAS DONE?):




ANY OTHER MEDICAL CONDITIONS?
YES   NO
IF YES, PLEASE EXPLAIN:




DESCRIBE YOUR GENERAL HEALTH: