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ULTRASOUND SCREENING FORM CAROTID/VENOUS/ARTERIAL
Diagnostic Radiology Center of the Treasure Coast,INC
AJAY K. GOYAL,M.D.,BOARD CERTIFIED RADIOLOGIST
ULTRASOUND SCREENING FORM
CAROTID/VENOUS/ARTERIA
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:
CAROTID
BRUIT
WEAKNESS
STROKE
SURGERY
RT
OR
LT
VISUAL CHANGES
HEADACHE
DIZZINESS
HIGH BLOOD PRESSURE
SMOKER
MEMORY LOSS
OTHER
LEGS
PAIN
SWELLING
DISCOLORATION (BLUE OR RED)
HOT EXTREMITY(S)
COLD EXTREMITY(S)
CELLULITIS
POOR CIRCULATION
IF YES TO ANY WHICH LEG OR ARM? RT LEG /LT LEG RT ARM/LT ARMHOW LONG?
I accept to above all terms and condition
Submit