Lumbar Spine MRI Report Form
Complete this form to document lumbar spine MRI findings, impression, and report details.
Patient and Exam Identification
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record or Report ID
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ordering Clinician / Referring Provider
*
Radiologist / Reader Name
*
Lumbar Spine MRI Findings
MRI Technique / Study Type
*
Please Select
Non-contrast lumbar spine MRI
Contrast-enhanced lumbar spine MRI
MRI with and without contrast
Limited lumbar spine MRI
Other
Alignment
*
Vertebral Body Height / Marrow Signal
*
Disc Findings by Level
*
Canal Stenosis / Foraminal Narrowing
*
Nerve Root Compression / Impingement and Conus / Cauda Equina Status
*
Impression and Report Submission
Impression / Summary
*
Urgent or Critical Finding
*
No urgent finding
Urgent finding present
Follow-up Recommendation
MRI Report Acknowledgment
*
I acknowledge this report is for clinical documentation and communication of MRI findings
I do not acknowledge
Submit Report
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