Medical Imaging Scan Log Form
Use this form to log details of medical imaging scans for operational record-keeping. Please complete all fields accurately.
Patient/Reference Identifier
*
Referring Department
*
Please Select
Emergency
Outpatient
Inpatient
Cardiology
Neurology
Oncology
Orthopedics
Other
Imaging Modality
*
Please Select
X-ray
CT
MRI
Ultrasound
PET
Mammography
Fluoroscopy
Other
Scan Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scan Time
*
Hour Minutes
AM
PM
AM/PM Option
Body Area Imaged
*
Please Select
Head/Brain
Chest
Abdomen
Pelvis
Spine
Extremities
Whole Body
Other
Scan Reason
*
Please Select
Routine Screening
Diagnosis
Follow-up
Pre-operative
Post-operative
Emergency
Other
Contrast Used
*
None
IV Contrast
Oral Contrast
Both IV and Oral
Other
Technologist/Operator Name
*
Scan Notes or Findings
Submit
Should be Empty: