Prescription

The document is a radiology x-ray request form containing fields for patient information including name, age, and sex, the patient's history and exam findings, diagnosis, area to scan, requesting physician information, and space for radiology resident or senior signature.

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Prescription

Uploaded by

yohannes fetene

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JUMC RADIOLOGY X RAY REQUEST FORM

Date:-------------------------------

MRN:-------------------------------

Patient information

Name: ------------------------------------------------- Age:----------------- Sex:-----------------

Summary of history and P/E findings------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------

Diagnosis------------------------------------------------------------------------------------------------------------------

Specific area to be scanned-------------------------------------------------------------------------------------------

Requesting physician name and signature------------------------------------------------------------------------

Comment-----------------------------------------------------------------------------------------------------------------------------
-------------------------------------

Name and signature of radiology resident /senior

-----------------------------------------------------------------

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