I think I'll seek a second opinion

So, I took my mom to an MRI / diagnostic facility this morning to have a couple of procedures performed. Upon signing in, she was asked to fill out some paperwork, including a recent medical history form. Here is one of the questions (fourth line down) from said form...

Ummm... mom made it through her visit without any complications, but after seeing this, I'm ain't so sure I would've has been comforble with them people poking on me.