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Creative Commons License
Enhanced FHA Imaging eForm, originally created by Dr. D. Page, is licensed under a GPL.   Update V12_Aug1_2023 by Dr. John Yap.
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Subject:



OBSTETRICAL US:
US for Gestational week(s) #:  

Calculated using EDC of (yyyy-mm-dd):

1st Trimester Dating OBS US
Detailed 18 week OBS US  
Antepartum bleeding OBS US
Nuchal Translucency OBS US
    NT at MedRay
    NT at RCH  
    NT at JPOCSC
    NT at BCWH

MODALITY:
X-ray Ultrasound CT Doppler

SIDE:
Left Right Bilateral

BODY PART:
Head Sinuses Carotids Thyroid
Chest Abdomen Pelvis Renal
Obstetrical Leg (DVT)
C-spine T-spine L-spine
Shoulder Humerus
Elbow Forearm
Wrist Scaphoid Hand
Hip Femur Knee
Lower leg Ankle Foot

CAR GUIDELINES


Change contact info as needed
Name:  
Ph:  
Fax:  

Call if positive Call result
Fax if positive Fax
Send to ER if positive

URGENT EMERGENT

Lab     Lab NOW


TEST PREPARATION:
US Abdomen
US Abdomen/Pelvis
US Renal
US Pelvic/OBS
Hysterosalpingogram (HSG)
US Thyroid/Scrotal