X-ray Report Form
An X-ray report form is a medical document, used by hospital, test labs and physician to analyze the inner body condition of a patient. It is a very common report form, widely used by hospitals. The report form provides details of patient’s interior body scan and intensity of illness.
Sample X-Ray Report Form
General Information
Name of Hospital/Test Lab________________
Name of Physician_________________
Name of Patient___________ Sex______ Age_______
Address__________ Phone__________ Email__________
X-ray Report Information
Report Title____________
Date of Report___/___/___
Test lab___________ Technician___________
Pathologist Name___________
Purpose_________ Illness/Dieses_______________
Body Part, which has been examined_______________
Present Condition of patient_______________________
Medicines given before the test____________________
Other test done before x-ray_______________________
Present treatment, prescription ____________________
Is it the first x-ray, if not than provide details of prior ones______________
Result of X-ray Report_____________
Remarks of Pathologist_________________
Signature____________ Date of Report Submission___/____/__
Report Recipient Information
Name of Recipient_____________ Designation_____________
His/Her Remarks, Comments__________________
Prescribed Treatment___________________
Changes in Medication__________________
Recommended any further test_____________
Signature____________ Date___/___/__
Category: Report Forms
