Diagnostic Imaging Request Form

Specialty: General Practitioner Diagnostic Imaging Request Form Patient Information: Patient Name: Sarah Jenkins Date of Birth: 15/03/1988 Gender: Female NHS Number: 123 456 7890 Referring Clinician Information: Referring Clinician Name: Dr. Emily White Practice Name: City Medical Centre Contact Number: 020 7946 0123 Date of Request: 1 November 2024 Type of Imaging Requested: X-ray Body Area/Specific View(s): Right Foot, AP and Lateral views Clinical Indication for Imaging (Reason for Request): Patient presents with acute onset of pain and swelling in the right foot after twisting it during a fall approximately 24 hours ago. Unable to bear full weight. No open wounds or gross deformity. Rule out fracture. Relevant Clinical History: * Mechanism of Injury: Twisting injury to right foot after a fall from a curb. * Onset: Approximately 24 hours prior to presentation. * Symptoms: Pain, swelling, difficulty weight-bearing. * Past Medical History: No significant past medical history. No history of previous fractures. * Medications: None. * Allergies: Penicillin (rash). Patient's Current Symptoms: Localised tenderness over the dorsum and lateral aspect of the right foot. Swelling noted around the ankle and midfoot. Pain rated 7/10 on movement and weight-bearing. Urgency of Request: Routine Additional Instructions/Considerations: N/A Consent obtained for imaging: Yes