DRCTC Ultrasound Pelvic

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

1^ST DAY OF LAST MENSTRAL PERIOD

POST MENOPAUSAL?

Yes No

IF YES HORMONE REPLACMENT THERAPY?

Yes No

DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING?

CYSTS

MASS

FIBROID

CANCER

HYSTERECTOMY

POLYPS

ABNORMAL BLEEDING

IRREGULAR PERIODS

PELVIC PAIN

NO

IF YES TO ANY PLEASE EXPLAIN

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