Upstate Medical Physics Data Form for Evaluating Fetal Dose for 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date form is completed' at the top of the document. This helps track when the information was gathered.
3. Fill in the 'Name of RSO' and 'Patient Information' sections, including details like Medical Record#, DOB, and Patient ID#.
4. In the 'Examination Information' section, provide details such as Facility Name, Room #, Type of Examination, and Equipment Manufacturer & Model.
5. Indicate patient size (XS, S, M, L, XL, XXL) along with height and weight measurements.
6. Answer questions regarding whether the uterus was in beam and if contrast was used. Specify detector configuration and pitch as applicable.
7. Complete X-Ray Techniques by filling in kVp, mAs, rotation time, and distances related to the uterus.
8. Finally, provide your contact information and confirm if further details are needed before saving your completed form.

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