Pancreatic Cyst Evaluation Form
Please complete all sections to assist in the clinical evaluation of a pancreatic cyst.
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Physician
Presenting Symptoms
*
Imaging Modality Used
*
Please Select
CT Scan
MRI
Ultrasound
EUS (Endoscopic Ultrasound)
Other
Cyst Size (in cm)
*
Cyst Location
*
Please Select
Head of Pancreas
Body of Pancreas
Tail of Pancreas
Uncinate Process
Other
Cyst Characteristics
Septations
Mural Nodules
Thickened Wall
Calcifications
Communication with Main Duct
Other
Recommendations / Next Steps
*
Submit Evaluation
Should be Empty: