@@SITETITLE@@: PET Evaluation Form

Study date

MM/DD/YYYY

Radiologist

Radiologist NPI

PET scan performed at outside institution PET scan performed at outside institution

No Yes

Date of baseline CT Date of baseline CT

MM/DD/YYYY

Date of most recent comparative study Date of most recent comparative study

MM/DD/YYYY

Are there any nodules noted in the CT scan? Are there any nodules noted in the CT scan?

No Yes

Are non-calcified nodules noted, all less than 6 mm? Are non-calcified nodules noted, all less than 6 mm?

No Yes

Nodules

READ before completing the Nodule Grid

BASELINE: Include all nodules >= 6.0 mm in average diameter. Others are OPTIONAL.
ANNUAL REPEAT: include all NEW nodules >= 3.0 mm in average diameter.
For BASELINE CT, all nodules are new unless there is a CT more than 3 years earlier.
For BASELINE CT, the nodules will automatically be sorted with the largest non-calcified nodules with a solid component coming first.
Note: hilar masses and focal consolidation should be included in the nodule grid.
The same nodule ID will be used on all subsequent CT and other forms. NEW nodules, even if LARGER, must follow nodules already listed.
For nodules recommended for biopsy or antibiotics, list the reason in the comments field in the corresponding column.

If no nodules were detected, you may skip this section.

Nodule ID	Nodule 1	Nodule 2	Nodule 3	Nodule 4	Nodule 5	Nodule 6	Nodule 7	Nodule 8	Nodule 9	Nodule 10
Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?	Is it new?
Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?	Endobronchial?
Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?	Most likely location?
SUV	SUV	SUV	SUV	SUV	SUV	SUV	SUV	SUV	SUV	SUV
Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series	Nodule seen in series
Nodule seen in images	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)	Nodule seen in image (Low) - Nodule seen in image (High)
Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status	Nodule status
Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency	Nodule consistency
Length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)	length (mm)
Maximum width (mm)	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width	Maximum width
Mean diameter (mm)	-	-	-	-	-	-	-	-	-	-
Height (mm)	Height	Height	Height	Height	Height	Height	Height	Height	Height	Height
Volume (mm ³ )	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered	Volume Manually entered
Solid comp. of part-solid	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width	Solid comp. length x Solid comp. width
Solid mean diameter(mm)	-	-	-	-	-	-	-	-	-	-
Smooth edges	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Calcifications	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Index Nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule	Index nodule
Spiculated	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Distance from the costal pleura (mm)?	Distance	Distance	Distance	Distance	Distance	Distance	Distance	Distance	Distance	Distance
Action	Action	Action	Action	Action	Action	Action	Action	Action	Action	Action
Comment	Comment	Comment	Comment	Comment	Comment	Comment	Comment	Comment	Comment	Comment
Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis	Pathologic diagnosis

Small non-calcified nodules are present

Small calcified nodules are present

PET details - lung and nodules

PET details - lymph nodes

Other clinically significant ancillary finding? Other clinically significant ancillary finding?

No Yes

Organ/Location

Describe

Organ/Location

Describe

Comments

Any other findings

Follow-Up

Follow-up

When

MM/DD/YYYY
Now 1 month 3 months 6 months 1 year Other

Impression

Nodules

No evidence of abnormal uptake. Follow-up as recommended above.

Uptake as described above. Follow-up as recommended above.

Nodule(s) unchanged, as described above. Follow-up as recommended above.

Other findings

No other abnormalities.

Other abnormalities and suggested follow-up as described above.

Diffuse abnormalities.

Impression remarks

Delete

Sample, Sammy G ST0001

PET Evaluation Form 1234567890

Nodules

READ before completing the Nodule Grid

Lung-RADS

Follow-Up

Impression