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PT Name/DOB/DOS
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Previous studies:
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Referring Doctor:
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Risk Factors:
• • •
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Cardiologist:
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Symptoms:
• • •
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Ordering Doctor:
• • •
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Comments:
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Technologist:
• • •
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Description of Procedure:
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Right Examination Results
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Right Brachial Pressure
• • •
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Right Brachial Waveform
• • •
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Right Thigh Pressure
• • •
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Right Thigh Waveform
• • •
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Right Upper Calf Pressure
• • •
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Right Upper Calf Waveform
• • •
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Right Lower Calf Pressure
• • •
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Right Lower Calf Waveform
• • •
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Right Ankle Posterior Tibial Pressure
• • •
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Right Ankle Posterior Tibial Waveform
• • •
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Right Ankle Dorsalis Pedis Pressure
• • •
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Right Ankle Dorsalis Pedis Waveform
• • •
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Right Toe Pressure
• • •
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Right Toe Waveform
• • •
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Left Examination Results
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Left Brachial Pressure
• • •
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Left Brachial Waveform
• • •
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Left Thigh Pressure
• • •
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Left Thigh Waveform
• • •
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Left Upper Calf Pressure
• • •
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Left Upper Calf Waveform
• • •
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Left Lower Calf Pressure
• • •
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Left Lower Calf Waveform
• • •
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Left Ankle Posterior Tibial Pressure
• • •
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Left Ankle Posterior Tibial Waveform
• • •
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Left Ankle Dorsalis Pedis Pressure
• • •
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Left Ankle Dorsalis Pedis Waveform
• • •
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Left Toe Preassure
• • •
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Left Toe Waveform
• • •
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Right ABI
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Left ABI
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Right Rest ABI
• • •
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Left Rest ABI
• • •
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Right Exercise ABI
• • •
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Left Exercise ABI
• • •
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Right TBI
• • •
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Left TBI
• • •
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Right ABI
• • •
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Left ABI
• • •
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Right Segmental pressures are
• • •
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Left Segmental pressures are
• • •
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Right PVR Waveforms are
• • •
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Left PVR Waveforms are
• • •
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Right Doppler Waveforms are
• • •
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Left Doppler Waveforms are
• • •
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Additional Comments - Right
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Additional Comments - Left
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Right Interpretation
• • •
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Left Interpretation
• • •
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Lower Venous System
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Referral Sautation
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