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X-ray Report Form
Verbal reports are free of charge. If you wish to schedule a surgery please use the REFERRAL FORM instead.
The form can be edited/added to at a later time; a link will be emailed to you following form submission.
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* Indicates required question
Vet:
*
Referring Veterinary Surgeon
Your answer
Practice:
*
Veterinary Practice Name
Your answer
Phone:
*
Please enter your preferred contact number
Your answer
Mobile Phone:
Providing your mobile phone number assists more timely reporting. You may leave this blank.
Your answer
Patient Name:
*
Given name ONLY
Your answer
Patient Surname:
*
Surname ONLY
Your answer
Patient Age:
*
In years and months, or in weeks if less than 6 months old
Your answer
Patient species:
*
Dog
Cat
Other:
Patient Breed:
*
Your answer
Patient Sex:
*
Male
Male Neutered
Female
Female Neutered
Patient Weight (kg):
*
Your answer
Body Condition Score:
*
A score of 4 to 5 indicates IDEAL body condition i.e. Ribs palpable without excess fat covering. Waist & abdominal tuck apparent.
Emaciated
1
2
3
4
5
6
7
8
9
Severely Obese
Localisation on Exam:
*
Did the clinical exam demonstrate CONSISTENT discomfort in any of the following areas (you may choose more than one).
Nothing Convincing
Hip
Stifle
Shoulder
Elbow
Carpus
Cervical spine
Thoracolumbar spine
Lumbosacral spine
Other:
Required
Primary Complaint & Duration:
*
What is the patient's primary complaint, and how long has problem been present?
Your answer
Clinical History:
*
Please describe findings on recent clinical examination/s and summarise important points of the clinical history
Your answer
Other Clinical Problems:
*
List any other notable clinical problems, e.g. other orthopaedic disease, diabetic, or write NA if none.
Your answer
Progression:
*
Deteriorating Slowly
Deteriorating Rapidly
Deteriorating ACUTELY
STATIC
Gradually Improving
Rapidly Improving
Other:
CURRENT lameness:
*
Indicate the CURRENT level of lameness. If lameness is not a feature select value of zero.
not lame
0
1
2
3
4
5
6
7
8
9
10
holding limb off ground
Lameness at WORST:
*
Indicate the level of lameness at it's WORST. If lameness is not a feature select value of zero.
not lame
0
1
2
3
4
5
6
7
8
9
10
holding limb off ground
Are NEUROLOGICAL DEFICITS apparent?
*
Indicate the CURRENT degree of neurological deficits (if any). If no evidence of neurological deficts select value of zero.
normal
0
1
2
3
4
5
6
7
8
9
10
paralysis
Medications:
*
Please specify dose, duration and efficacy of any CURRENT and PREVIOUS medications or write NA if none.
Your answer
Xrays submitted?
*
ALL radiographs (and / or advanced imaging) relevant to the case should be submitted. It is preferable to submit images at highest quality; DICOM files are recommended. A file upload button can be found in the footer of every page of this website.
X-rays have been submitted
X-rays will be submitted later today
X-rays will be submitted tomorrow
Other:
Other Information / Comments:
You may leave this blank
Your answer
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