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Radiology
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MRI
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Reason for MRI Referral:
• • •
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Head
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Imaging Facility
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Date of Head MRI
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List the Findings...
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Cervical
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Imaging Facility
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Date of Cervical MRI
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List the Findings...
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ADD DX's FROM MRI FINDINGS
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Cervical Herniation
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Cervical Disc Bulge
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Cervical Disc Degeneration
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Cervical Foraminal Stenosis (Bone)
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Cervical Foraminal Stenosis (Disc)
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Cervical Spinal Stenosis
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Thoracic
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Imaging Facility
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Date of Thoracic MRI
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List the Findings...
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ADD DX's FROM MRI FINDINGS
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Thoracic Herniation
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Thoracic Disc Bulge
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Thoracic Disc Degeneration
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Thoracic Foraminal Stenosis (Bone)
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Thoracic Foraminal Stenosis (Disc)
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Thoracic Spinal Stenosis
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Lumbar
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Imaging Facility
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Date of Lumbar MRI
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List the Findings...
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ADD DX's FROM MRI FINDINGS
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Lumbar Herniation
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Lumbar Disc Bulge
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Lumbar Disc Degeneration w Discogenic Back Pain Only
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Lumbar Disc Degeneration with Lower Extremity Pain Only
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Lumbar Disc Degeneration with Discogenic Back Pain and Lower Extremity Pain
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Lumbar Disc Degeneration without mention of Lumbar Back Pain or Lower Extremity Pain
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Lumbar Foraminal Stenosis (Bone)
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Lumbar Foraminal Stenosis (Disc)
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Lumbar Spinal Stenosis
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Upper Extremity
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Select side of body
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Select Joint
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Imaging Facility
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Date of Upper Extremity MRI
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List the Findings...
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Select side of body
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Select Joint
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Imaging Facility
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Date of Upper Extremity MRI
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List the Findings...
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Lower Extremity
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Select side of body
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Select Joint
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Imaging Facility
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Date of Lower Extremity MRI
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List the Findings...
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Select side of body
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Select Joint
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Imaging Facility
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Date of Lower Extremity MRI
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List the Findings...
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CT Scan
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Reason for CT Referral:
• • •
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Head
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Imaging Facility
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Date of HEAD CT Scan
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List the Findings...
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Cervical
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Imaging Facility
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Date of Cervical MRI
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List the Findings...
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ADD DX's FROM CT SCAN FINDINGS
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Cervical Herniation
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Cervical Disc Bulge
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Cervical Disc Degeneration
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Cervical Foraminal Stenosis (Bone)
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Cervical Foraminal Stenosis (Disc)
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Cervical Spinal Stenosis
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Thoracic
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Imaging Facility
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Date of Thoracic MRI
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List the Findings...
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ADD DX's FROM CT SCAN FINDINGS
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Thoracic Herniation
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Thoracic Disc Bulge
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Thoracic Disc Degeneration
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Thoracic Foraminal Stenosis (Bone)
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Thoracic Foraminal Stenosis (Disc)
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Thoracic Spinal Stenosis
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Lumbar
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Imaging Facility
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Date of Lumbar MRI
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List the Findings...
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ADD DX's FROM CT SCAN FINDINGS
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Lumbar Herniation
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Lumbar Disc Bulge
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Lumbar Disc Degeneration
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Lumbar Foraminal Stenosis (Bone)
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Lumbar Foraminal Stenosis (Disc)
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Lumbar Spinal Stenosis
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Upper Extremity
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Select side of body
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Select Joint
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Imaging Facility
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Date of Upper Extremity CT Scan
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List the Findings...
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Lower Extremity
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Select side of body
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Select Joint
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Imaging Facility
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Date of Lower Extremity CT Scan
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List the Findings...
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