Form CMS10583 IDEAS Assessment

Imaging Dementia-Evidence for Amyloid Scanning Study Forms (IDEAS)
(version March 31, 2015)
AMYLOID PET ASSESSMENT FORM
Site ID:

Reader ID:

Subject ID:

Date of Read:

Radiopharmaceutical:
 F-18 florbetaben (Neuraceq™)
 F-18 florbetapir (Amyvid™)
 F-18 flutametamol (Vizamyl™)
Radiopharmaceutical dosage:

mCi

Scan Type:
 PET only
 Was the PET fused with separately obtained CT or MRI for interpretation?
 Yes
 No
 PET/CT
Was the PET component fused with separately obtained MRI for interpretation?
 Yes
 No
 PET/MRI
Was image quantification used to assist in interpretation?
 No
 Yes
Was comparison with prior imaging studies used to assist in interpretation?
 No
 Yes
If Yes, check all that apply:
 Brain CT
 Brain MRI
 Brain FDG-PET
Global Scan Result:
 Positive
Confidence level of interpretation:
 High
 Intermediate

Imaging Dementia-Evidence for Amyloid Scanning Study Forms (IDEAS)
(version March 31, 2015)
 Low
 Negative
Confidence level of interpretation:
 High
 Intermediate
 Low
 Uninterpretable (the image is technically inadequate for interpretation and therefore no
final impression can be obtained)
Specify:
Electronic Signature of Radiologist/Nuclear Medicine Physician Reader