Fistula Ultrasound Evaluation
Please complete this clinically aligned assessment for ultrasound-based fistula evaluation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Clinician/Department
*
Purpose of Evaluation / Indication
*
Fistula Location and Type
*
Please Select
Left arm – Radiocephalic
Left arm – Brachiocephalic
Left arm – Brachiobasilic
Right arm – Radiocephalic
Right arm – Brachiocephalic
Right arm – Brachiobasilic
Other
Relevant Symptoms and Clinical History
Prior Procedures or Dialysis Access History
Ultrasound Findings Summary
*
Impression and Recommended Next Steps
*
Submit Evaluation
Should be Empty: