Lumbar Spine MRI Report

Lumbar Spine MRI Report
Please complete this form to document and communicate the findings of a lumbar spine MRI examination.
Patient Full Name
First NameLast Name
Patient Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Gender
Other
Referring Physician Name
First NameLast Name
Date of MRI Scan
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinical Indication (Reason for MRI)
MRI Technical Details (e.g., sequences, contrast use)
Findings: Vertebral Bodies
Findings: Intervertebral Discs
Findings: Spinal Canal and Nerve Roots
Other Relevant Findings (e.g., soft tissues, incidental findings)
Impression / Summary
Recommendations (if any)
Radiologist Name
First NameLast Name
Radiologist Signature
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