A radiology questionnaire consists of a list of questions usually asked by a hospital or diagnostic clinic to a patient who has come for any type of radiology test which uses imaging techniques to know about the internal organs and bones inside a person’s body.

There can be different types of radiology examinations like ultrasound, X-rays, CT scans etc which help doctors identify disorders by taking pictures using controlled radiation procedures. Hence, some clinics and hospitals may want to take the patient’s personal information and other details about his past medical history or reasons for a radiology test.

Sample Radiology Questionnaire:

Name of patient: ____

Address: ______

Phone number: _____

Email address: ______

Date of birth: ________

Gender: __________

Date of examination: _________

• Please mention the type of radiology examination that you have come here for.

• How did you come to hear about our organization?

a) Referred by doctor

b) Advertisements

c) Friends/family

d) Others

• Why are you having a radiology examination? Give reasons in brief. ______

• Did you have any radiology examination before? ______

• What symptoms are you facing now? Explain in brief.________

• Are you in pain? If yes, please mention the area where you feel pain. ______

• Are you taking any medication? If yes, please give names. ________

• Please mention any medical condition that you currently have. ______

• Have you had any surgery in the last 1 year?

a) Yes

b) No

• Please mention what kind of surgery you had, if any. ________

• Do you have a history of cancer? If yes, please mention what area was affected. _______

• Have you taken any course of radiation therapy for any ailment before? If yes, please explain briefly. _________

• Did you bring any previous medical reports? _____

(Only for female patients)

• Are you pregnant?

a) Yes

b) No

c) Don’t know

• When did you last have your menstrual period? ______