Leg Vein Mapping US Technologist Worksheet St Vincents Riverside Southside Clay St Johns Imaging Center Arlington ER Westside ER Beach ER Optimal Forbes Southside Clay Mandarin Westside St Johns Town Center Orange Park Patient Name: MMI: Age: History/Symptoms: RIGHT Great Saphenous Vein RIGHT Leg Deep Veins Occlusive Nonocclusive No Clot mm Saphenofemoral Common Femoral No Clot Nonocclusive Occlusive mm Proximal Thigh Proximal Femoral No Clot Nonocclusive Occlusive mm Mid Thigh Mid Femoral No Clot Nonocclusive Occlusive mm Above Knee Distal Femoral No Clot Nonocclusive Occlusive mm Below Knee Popliteal No Clot Nonocclusive Occlusive mm Mid Calf Trifurcation mm At Ankle Posterior Tibial No Clot Nonocclusive Occlusive LEFT Greater Saphenous Vein LEFT Leg Deep Veins mm Saphenofemoral Common Femoral No Clot Nonocclusive Occlusive No Clot Nonocclusive Occlusive mm Proximal Thigh Proximal Femoral No Clot Nonocclusive Occlusive mm Mid Thigh Mid Femoral No Clot Nonocclusive Occlusive mm Above Knee Distal Femoral mm Below Knee Popliteal No Clot Nonocclusive Occlusive No Clot Nonocclusive Occlusive mm Mid Calf Trifurcation No Clot Nonocclusive Occlusive mm At Ankle Posterior Tibial Other Findings: Sonographer's Impression: Sonographer's Name, Date & Time:

Images

Not Intended for Treatment Planning MI-0635
(Revised 6/2025) Tech Wrksht - "Leg Vein Mapping US Chrtform"