Arm 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: Cephalic Basilic RIGHT ARM RIGHT ARM Nonocclusive Occlusive mm mm Upper Arm No Clot Int Jugular Vein No Clot Occlusive Nonocclusive mm mm Lower Arm Subclavian Vein No Clot Nonocclusive mm mm Occlusive Upper Forearm Axillary Vein No Clot Occlusive Nonocclusive mm mm Lower Forearm Brachial Vein Nonocclusive No Clot Occlusive Cephalic Vein No Clot Nonocclusive Occlusive mm Axillary Vein: Basilic Vein Patent Not Patent mm Brachial Vein: Radial Artery Patent Not Patent mm Radial Artery: Ulnar Artery mm Ulnar Artery: Cephalic Basilic LEFT ARM LEFT ARM Nonocclusive Occlusive mm mm Upper Arm Int Jugular Vein No Clot No Clot Nonocclusive Occlusive mm mm Lower Arm Subclavian Vein No Clot Nonocclusive Occlusive mm mm Upper Forearm Axillary Vein No Clot Nonocclusive Occlusive mm mm Lower Forearm Brachial Vein Cephalic Vein No Clot Nonocclusive Occlusive mm Axillary Vein: Basilic Vein No Clot Nonocclusive Occlusive Patent Not Patent mm Radial Artery Brachial Vein: mm Radial Artery: Ulnar Artery Patent Not Patent mm Ulnar Artery: Sonographer's Impression: Sonographer's Name, Date & Time:

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Not Intended for Treatment Planning MI-0632
(Revised 6/2025) Tech Wrksht - "Arm Vein Mapping US Chrtform"