Category III - Pain/Other Symptoms/Impairment Information

Disability Case Development Information Collections

CE - Resting Doppler Evaluation

Category III - Pain/Other Symptoms/Impairment Information

OMB: 0960-0555

Document [pdf]
Download: pdf | pdf
[claimant name]

[case_id#]

[case_owner_desk_name]

INSTRUCTIONS FOR RESTING ARTERIAL FLOW DOPPLER TESTING
(Complete and Return WITH Report)

DOPPLER PROTOCOL
Systolic Pressures
Brachial
Systolic Pressure

Right

Left

Right Systolic Pressure

Left Systolic Pressure

Posterior Tibial
Dorsalis Pedis

Ankle/Brachial Ratio: (Use the higher ankle reading from each leg divided by the higher brachial reading.)
Higher Ankle Pressure =
Higher Brachial Pressure
Ankle/Brachial
Ratio

Ankle/Brachial Ratio

Right

Left

Please send Doppler pulse wave tracings.

Technician's Signature ________________________________________ Date _____________________


File Typeapplication/pdf
File TitleResting Doppler Evaluation
AuthorAnna Ray SSD-137
File Modified2022-07-01
File Created2022-07-01

© 2024 OMB.report | Privacy Policy