Patient Data
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DATE OF BIRTH:
DATE OF STUDY:
Bilateral lower extremity venous ultrasound
Right lower extremity venous ultrasound
Left lower extremity venous ultrasound
Standing
Reverse Trendelenberg
Supine
Peter Tusa RVT
Danielle Nelson RVT
Tori Rago RVT
Anzhela Yatina RVS
Devan Salle RVS
David Cohen MD, RPVI, RVT
MD:
Select one
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Amit V. Patel, MD
Kevin V. James, MD
Michael Resnikoff, MD
Thomas Lee, MD
Omer Riaz, MD
Brian Wernick, MD
compressible
non-compressible
non-compressible
absent
is patent
is absent
could not be visualized
contains chronic thrombus
contains acute thrombus
contains thrombus
contains post-phlebitic changes
contains webbing
is closed, S/P ablation
normal
absent
phasic (normal)
absent
continuous
pulsatile
no reflux (<0.5 sec)
reflux (>0.5sec)
superficial
right
vein
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FIRST NAME:
LAST NAME:
DATE OF BIRTH:
DATE OF STUDY:
TYPE OF STUDY:
PATIENT POSITION:
TECHNOLOGIST:
Your practice name
Test address 123
New York City, NY 10016
t 973-001-0001
Advanced Vascular Vein Care
131 Madison Avenue
Morristown, NJ 07960
t 973-540-9700
Dr Name Here
John Doe, MD
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Red = incompetent
Blue = competent
Black = closed/absent