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Deep R Brachial Color Y N Comp Y N Nl Aug Y N

Upper Extremity Venous Doppler Worksheet. Name: __________________________ Male Female Date: _________________ DOB: __________________________ Tape #: _________________

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Deep R Brachial Color Y N Comp Y N Nl Aug Y N

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  1. Upper Extremity Venous Doppler Worksheet Name: __________________________ Male Female Date: _________________ DOB: __________________________ Tape #: _________________ Diagnosis: _______________________ Referring MD: _________________ Indications□ Rule out DVT □ Edema □ Pain □ Other_______________________ Deep L Jugular Color Y N Nl Aug Y N Deep R Jugular Color Y N Nl Aug Y N Superficial R Cephalic Color Y N Comp Y N Nl Aug Y N Superficial L Cephalic Color Y N Comp Y N Nl Aug Y N Deep R Subcalvian Color Y N Nl Aug Y N Deep L Subcalvian Color Y N Nl Aug Y N Deep R Axillary Color Y N Comp Y N Nl Aug Y N Deep L Axillary Color Y N Comp Y N Nl Aug Y N Superficial R Basalic Color Y N Comp Y N Nl Aug Y N Superficial L Basalic Color Y N Comp Y N Nl Aug Y N Deep R Brachial Color Y N Comp Y N Nl Aug Y N Deep L Brachial Color Y N Comp Y N Nl Aug Y N Deep R Radial Color Y N Comp Y N Nl Aug Y N Deep L Radial Color Y N Comp Y N Nl Aug Y N Deep R Ulnar Color Y N Comp Y N Nl Aug Y N Deep L Ulnar Color Y N Comp Y N Nl Aug Y N Comp = Compression Nl Aug = Normal augmentation Comments

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