Henrico Retired Firefighter Patient Medical History Form

Henrico Firefighter Retiree Health Questionnaire
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient E-Mail*
example@example.com
Date of Birth*

MonthDayYear
Gender

MaleFemaleDecline
How many years have served as a firefighter? (optional)

Less than 1 year1-5 years5-10 years10-15 years15-20 yearsGreater than 20 years
How many years have you been retired?(optional)

Less than 1 year1-5 years5-10 years10-15 years15-20 yearsGreater than 20 years
I hereby release the screening physician, Hampton Roads Ultrasound and all other healthcare volunteers from all responsibility in connection with this screening exam. I understand that I will only be screened for risk factors or symptoms of cardiovascular disease and cancer and that this screening does not constitute a complete medical exam or diagnosis, and that I do not have a physician-patient relationship with the screening physician by virtue of this screening exam. I further understand that I will receive a copy of my screening results. I may receive a follow-up phone call from a licensed medical provider. It is solely my responsibility to seek any appropriate follow-up medical treatment as indicated by my screening results. No one may use my examination results for any purpose, other than statistical study as long as no identifying information is published. I consent to ultrasound testing performed by Hampton Roads Ultrasound. I have read and understand this form and understand the information presented.

To view our full HIPPA agreement click here.
If needed, can we share your results with your primary care physician or specialists?*

YesNo
Primary Care Physician

First NameLast Name
Exam Descriptions

Carotid screenings are designed to detect plaque development in carotid arteries that can result in cerebrovascular accidents (Stroke) and Transient Ischemic Attacks (TIA/Mini stroke). A detailed carotid ultrasound exam can identify structural and blood flowabnormalities. Carotid screenings have the ability for early detection of undiagnosed abnormalities. Participants will be required to expose the neck on both sides. An ultrasound probe will be moved along the side of the neck to evaluate the carotid arteries.

An echocardiogram is an ultrasound of the heart that helps diagnose damaged cardiac tissue and heart chamber enlargement. It can also detect fluid around the heart and poorly functioning heart valves as well as abnormal masses in the heart muscle. A detailed echocardiogram can detect poorly functioning heart valves abnormalities in the heart muscle. Participants will be required to remove their shirt, a drape will be placed over the chest for privacy. Gel will be placed on the chest. An ultrasound probe will be moved along the left side of the chest and under the breast.

A thyroid ultrasound is used to evaluate the soft tissue and vasculature of the gland. A detailed analysis of tissue density has been shown to have a greater than 95% accuracy at detecting malignancy. Multiple longitudinal and cross-sectional images are used to assess the thyroid for suspicious tumors and cysts. Participants will be required to expose the neck on both sides. An ultrasound probe will be moved along the side of the neck to evaluate the thyroid gland.

The pelvic ultrasound is used to evaluate the endometrium, uterus and ovaries. This exam is capable of providing views of these pelvic contents. The transabdominal pelvic ultrasound involves moving a specialized transducer, outside the body, across the lower half of the abdomen and pelvis. A transabdominal exam provides a view of the pelvic organs, but there may be limitations in measuring cysts and masses.

Abdominal Ultrasound includes the liver, gall bladder, kidneys, and spleen. The abdomen provides the largest opportunity for the development of pathology. The abdominal organs are often either the origin of cancerous lesions or the direct target of metastasis. Abdominal Ultrasound evaluates the liver, gall bladder, kidney, and spleen. Participants will be required to expose the abdomen. An ultrasound probe will be moved along the length and the sides of the abdomen organs. In an abdominal complete ultrasound, all organs are identified and surveyed in multiple planes of view, color flow doppler is also used to evaluate masses.

The abdominal aorta ultrasound screenings evaluate the risk of abdominal aorta aneurysm and potential aorta tumors. This exam surveys the abdomen from the sternum to the pelvis and bifurcation of the 63abdominal aorta. The detailed abdominal aorta ultrasound involves evaluating the size and characteristics of the aorta. Participants will be required to expose the abdomen. An ultrasound probe will be moved along the length of the abdomen to assess the aorta.

A scrotal ultrasound is often the first test performed to evaluate the possibility of testicular cancer. Ultrasound has been proven to be instrumental in detecting lesions in the testicle. Imaging includes multiple views in the transverse and longitudinal and oblique planes to evaluate the testicle with color doppler imaging as well. The test requires disrobing to expose the scrotum. Measurements of the size of the scrotum and any abnormalities are recorded and communicated to the reading radiologist. This examination is intensely sensitive for the participant and require complete privacy as the client will be required to disrobe and expose the scrotum.

Bladder Ultrasound can evaluate the lining of the bladder and the musculature of the organ to determine if there are tumors, cysts or obstructive stones. The bladder ultrasound involves moving a specialized transducer, outside the body, across the lower half of the abdomen and pelvis. This ultrasound provides a view of the bladder and its contents.
Acknowledgement - Receipt of Notice of HIPPA Agreement and Privacy Practices and Exam Descriptions.*

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Allergies*
Risk Factors (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisNeurological DisordersBleeding DisordersLung DiseaseEmphysemaExcessive alcohol useCancerFamily history of cancerNoneOther
Surgical History*
Current symptoms*

Leg cramps with walking/pain with walkingTenderness in abdomenDifficulty speakingBack painDizzinessHeadachesNumbness or weakness on one side of bodyLoss of balance or coordinationSudden loss of visionTesticular painTesticular swellingAbnormal testicular massPelvic painAbnormal vaginal bleedingAdnexal (right or left pelvic pain)Abnormal hot or cold sensitivityChest painPalpitationsShortness of breath at restAbnormal shortness of breath on exertionEasy bruisingHallucinationsConfusionNose bleedsMouth soresDiarrheaNoneOther
Appointment*
Screening Location:

908 E. Nine Mile Rd

Highland Springs, VA

23075
I certify that all the information provided is accurate to the best of my ability and I consent to the cardiovascular and/or early detection cancer screening examinations.
Signature*

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Henrico Firefighter Retiree Health Questionnaire

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