Prostate MRI Assessment Form
Please complete this form to provide a structured clinical and radiological assessment for prostate MRI cases.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Physician
*
Patient Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Indication (e.g., elevated PSA, abnormal DRE, prior biopsy)
*
Date of MRI Scan
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MRI Scanner Type
*
Please Select
1.5 Tesla
3 Tesla
Other
Previous Prostate Biopsy?
*
Yes
No
Prostate-Specific Antigen (PSA) Level (ng/mL)
PI-RADS Assessment Table
*
Rows
Peripheral Zone
Transitional Zone
Anterior Fibromuscular Stroma
Lesion 1
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Lesion 2
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Lesion 3
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Overall PI-RADS Score
*
Please Select
1
2
3
4
5
Extraprostatic Extension (EPE)
*
Not present
Indeterminate
Present
Seminal Vesicle Invasion
*
Not present
Indeterminate
Present
Lymph Node Involvement
*
Not present
Indeterminate
Present
Other Relevant Findings (e.g., bone metastasis, bladder involvement)
Impression and Recommendations
*
Submit Assessment
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