Download Royal Adelaide Hospital Department of Radiology mrireqrah

Royal Adelaide Hospital
Department of
Radiology
mrireqrah
REQUEST FOR MAGNETIC RESONANCE IMAGING
Patient Surname
Given Names
Address
Home
RAH U.R.
Work
Date of Birth
For Exclusion of :MRI is initial imaging
modality for diagnosis
WARD
For Further Investigation of :Secondary imaging, diagnosis uncertain or
to assess extent or severity of the condition
Appointment
For Monitoring of :Diagnosis confirmed, MRI to assess
progress following treatment
HEAD
Tumour of Brain or Meninges
Acoustic Neuroma
Inflammation of Brain or Meninges
Congenital malformation of Brain or Meninges
Epilepsy
monitoring only)
Stroke
monitoring only)
Venous Sinus thrombosis
(F.I. or
(F.I. or
Skull Base or Orbital Tumour
Pituitary Tumour
Toxic, metabolic or ischaemic encephalopathy
Head trauma
monitoring only)
Demyelinating disease of Brain
(F.I. or
MRA Carotid or Vertebral Artery dissection (Neck)
MRA Stroke
(Exclusion or F.I. only)
MRA Venous Sinus thrombosis
(Exclusion or F.I.
only)
MRA Intra-cranial aneurysm
(Exclusion or F.I.
only)
MRA Intra-cranial arterio-venous malformation
SPINE
3 contiguous regions or 2 non-contiguous regions
MRA Carotid or Vertebral Artery dissection (Head)
1 region or 2 contiguous regions
Infection
Demyelinating disease
Myelopathy
Cervical radiculopathy
monitoring only)
Spinal canal stenosis
monitoring only)
Trauma
monitoring only)
Tumour
Congenital malform cord, cauda equina, Meninges
Syrinx (congenital or acquired)
Sciatica
monitoring only)
Previous spinal surgery
(F.I. or
monitoring only)
(F.I. or
(F.I. or
(F.I. or
(F.I. or
MUSCULO-SKELETAL
Tumour of bone or connective tissue
Osteo-necrosis
Infection of bone or connective tissue
Gaucher Disease
(monitoring only)
Derangement of Shoulder or supporting structures
Derangement of Ankle or supporting structures
Derangement of Wrist or supporting structures
Derangement of Hip or supporting structures
Derangement of Knee or supporting structures
Derangement of TMJ or supporting structures
Derangement of Elbow or supporting structures
Post Inflammatory or post traumatic physeal fusion in person under 16 years of age (F.I. or monitor only)
OTHER EXAMINATIONS
Obstruction of SVC, IVC or major pelvic vein (excl or FI)
Congenital disease of Heart or great vessel <16 excl of FI )
Pelvic or abdominal mass (under 16 FI or monitoring only)
Mediastinal mass
(< 16 y.o. FI or
monitor only)
Adrenal mass in patient with an otherwise resectable
malignancy
(F.I. only)
Other Clinical Notes or Examinations
Tumour of Heart or great vessel
(exclusion or F.I.
only)
Abnormality of thoracic Aorta
(exclusion or F.I.
only)
Congenital Uterine or Ano-rectal anomoly (<16 FI or monitor)
Gaucher Disease
(< 16 y.o. FI or
monitor only)
MRA vascular anomoly in patient with a prior anaphylactic
reaction to iodonated contrast agent
(exclusion or FI
only)
Referring Specialist
Signature
Specialty
Referrer's Address or Royal Adelaide Hospital Unit or Ward
Provider Number
Phone
Date
FAX