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PORT ST. LUCIE FACILITY
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16 SLICE LOW DOSE CT SCAN
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16 SLICE LOW DOSE CT SCAN
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DIGITAL X-RAY
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3D BREAST ULTRASOUND
DEXA SCAN
CT VIRTUAL COLONOSCOPY
3D TOMO MAMMOGRAPHY
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ULTRASOUND SCREENING FORM
Diagnostic Radiology Center of the Treasure Coast,INC
AJAY K. GOYAL,M.D.,BOARD CERTIFIED RADIOLOGIST
ULTRASOUND SCREENING FORM
FOR ABD/RENAL/RETRO
PLEASE PROVIDE THE FOLLOWING INFORMATION. (PRINT CLEARLY)
NAME
Date
D.O.B
Age
REFERRING PHYSICIAN
REASON FOR EXAM (SYMPTOMS)
WHEN DID SYMPTOMS FIRST BEGIN?
SURGICAL HISTORY
PREVIOUS RADIOLOGY/ULTRASOUND STUDIES
ANY PERSONAL HISTORY OF THE FOLLOWING:
KIDNEY- CYSTS STONES HYDRONEPHROSIS MASS
GALLBLADDER- STONES SLUDGE POLYPS
PANCREAS- PANCREATITIS CYST MASS
LIVER- MASS CYST CIRRHOSIS ELEVATED LIVER FUNCTION TEST
Nothing
ASCITIES
Yes
No
AORTIC ANEURYSM
Yes
No
IF YES HOW LONG AGO?
SURGICALLY REPAIRED?
Yes
No
I accept to above all terms and condition
Submit