CHIROPRACTIC X-RAY REPORT

Patient Name:____________________ D.O.B.: __________File #_______
Series_________________Date:______________

KEY:   check if unremarkable,
           circle if present.
               slight   –   mild – moderate – severe
               1-24% 25-49%   50-74%    75-100%
ALIGNMENT
Scoliosis:
C/S Levo-scoliosis-Dextro-scoliosis   Si Mi M S
T/S Levo-scoliosis-Dextro-scoliosis   Si Mi M S
L/S Levo-scoliosis-Dextro-scoliosis   Si Mi M S
T/S Kyphosis: increased decreased   Si Mi M S
Lordosis:
Georges Line: Smooth or Break at _____
C/S Lordosis: Increased    Decreased   Si Mi M S
             C/S   Loss of Lordosis
             C/S Reversal of Lordosis   Si Mi M S
Swischuk, Spinal-Lamina Line: C123
L/S: Lordosis Increased Decreased   Si Mi M S
Head:
        Tilt:          Left      Right            Si Mi M S
        Carriage: forward:                   Si Mi M S
Pelvic Unleveling: _____mm high on Right - Left
Other:

CARTILAGE
Disc Spaces:
Cervical – decreased at _________
Thoracic – decreased at _________
Lumbar - decreased at __________

Cervical – Sclerosis at _________
Thoracic – Sclerosis at _________
Lumbar - Sclerosis at _________

Sacral-Iliac Joints, comments, ___________

Acetabular Joint Spaces: comments ____

Costal cartilages comments:

Nuclear Impressions,
Vacuum Phenomenon at __________

Other:

BONE
Bone Density:       Good -- Fair -- Poor
Congenital Anomalies: Sella Turcica <16x12mm
      Cervical Rib, Dens   Posterior Ponticle
Foramina Occlusion: Seg. _______Si Mi M S
Spinal Canal Stenosis:
Si Mi M S    C/S >16,14,13,12mm
Si Mi M S    L/S > 15mm (Lat. View)
                                  Seg .____. ____mm.
Anterior/Retro/Spondylolisthesis, Spondylosis
Segment ______ Grade ______
Spina Bifida: Segment _______
Transitional Segment: _______
RA & Down’s Syn. C/S Flex Lat.View X-Ray Taken
Trauma: Recent or Past Hx of :_____
Compression/Fx. Of :_________
Arthritides: Scheuermans’s, levels _____
Pagets, Osteoarthrosis , Seg. _______
Infection Suspected at _________
Other:

SOFT TISSUES
ADI (<4mm)
RPI(<12mm) RLI(<22mm) (>12 hrs. post trauma)
Lung Apices Clear
Tracheal Air Shadow Divination: Left Right
Calcification:
Trachea Larynx
Aorta: Abdominal Thoracic
Other:
PATHOLOGIES:
None Apparent
Referral to: __________________ for further investigation of ___________________
CLINICAL IMPRESSIONS:

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