Stroke CT Evaluation Form
Complete this form to document and evaluate stroke-related CT findings, clinical context, and recommended next steps.
Patient and Exam Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex
*
Female
Male
Intersex
Prefer not to say
Medical Record Reference
Referring Clinician Name
*
First Name
Middle Name
Last Name
Facility / Location
*
Please Select
Emergency Department
Inpatient Unit
Outpatient Clinic
Imaging Center
Other
Exam Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
CT Modality / Exam Type
*
Please Select
Non-contrast Head CT
CT Angiography (CTA) Head and Neck
CT Perfusion
CT Head with Contrast
Other
Stroke Presentation and Clinical History
Last Known Well / Symptom Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Presenting Symptoms
*
Weakness
Speech difficulty
Facial droop
Altered mental status
Vision changes
Severe headache
Loss of balance/coordination
Other
Suspected Stroke Type
Please Select
Ischemic
Hemorrhagic
Transient Ischemic Attack (TIA)
Unknown
Other
Relevant History
Prior stroke
Prior TIA
Atrial fibrillation
Anticoagulant use
Recent trauma
Seizure at onset
Recent surgery
Other
Anticoagulant Details
NIHSS Score
Time Symptoms First Noted
Hour Minutes
AM
PM
AM/PM Option
Clinical Reason for CT / Additional Context
CT Findings Evaluation
Hemorrhage
*
Absent
Present
Indeterminate
Ischemic changes
*
Absent
Present
Indeterminate
Cerebral edema
Absent
Mild
Moderate
Severe
Mass effect
Absent
Mild
Moderate
Severe
Midline shift
None
<5 mm
5–10 mm
>10 mm
Hyperdense vessel sign
Absent
Present
Indeterminate
Loss of gray-white differentiation
Absent
Present
Indeterminate
ASPECTS score
Overall interpretation
*
No acute intracranial abnormality
Acute hemorrhage
Acute ischemic infarct
Mixed hemorrhagic and ischemic findings
Chronic changes only
Limited/nondiagnostic study
Other notable findings
Impression and Recommended Action
Radiology Impression / Summary
*
Suspected Stroke Subtype
Please Select
Ischemic stroke
Hemorrhagic stroke
TIA
Large vessel occlusion
Unknown/Indeterminate
Other
Recommended Next Steps
CTA
MRI
Neurology consult
Thrombectomy evaluation
Repeat CT
Transfer to stroke center
Other
Urgency Level
*
Routine
Urgent
Emergent
Results Communicated Immediately
*
Yes
No
Communicated To / Notes
Acknowledgment and Sign-off
Acknowledgment
*
I confirm this evaluation is complete and intended for clinical documentation and review
Evaluator / Clinician Sign-Off
*
Submit Evaluation
Submit Evaluation
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