Fistula Ultrasound Evaluation
Please complete this clinically aligned assessment for ultrasound-based fistula evaluation.
Patient Full Name
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First Name
Last Name
Date of Birth
*
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Month
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Day
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: