ID #: _____________ | Name: ____________________ | Date of Exam: ____/____/____ | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Right Hand | Left Hand | |||||||||
2nd | 3rd | 4th | 5th | 2nd | 3rd | 4th | 5th | |||
Total number of loops /3mm | ||||||||||
Calculated number loops /mm (x total number of loops/3) | ||||||||||
Number dilated /3 mm: | ||||||||||
Severity of dilation: 1 = mild, 2 = moderate, 3 = severe | ||||||||||
Avascular Pattern: 1 = periungual, 2 = patchy, 3 = both | ||||||||||
Severity of avascularity: 1 = mild, 2 = moderate, 3 = severe | ||||||||||
Predominant pattern: | ||||||||||
1 = open | 2 = crossed | |||||||||
3 = tortuous | 4 = undefined | |||||||||
5 = bushy | 6 = bushy | |||||||||
Number bushy loops /3mm: | ||||||||||
Number Branched Points /3mm: | ||||||||||
Number of Hemorrhages (any): | ||||||||||
GLOBAL | ||||||||||
Avg. end row loops /mm: | ||||||||||
Impression: 1 = Normal 2 = Abnormal | ||||||||||
Date entered ___/___/___ by (initials)____ | Date verified ___/___/___ by (initials)____ |