York County Fire and Life Safety

York County Fire and Life Safety Cardiovascular Disease and Cancer Screening
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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 flow abnormalities. 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.

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.

The EKG is a test that evaluated the electrical conduction of the heart. Dangerous rhythm abnormalities, like atrial fibrillation, can be detected. If undetected, this condition can result in thrombus (clots) being sent to the brain resulting in stroke. EKG sensors will be placed on the chest and legs for a few moments, the electrical activity of the heart will be monitored and displayed for cardiology interpretation.
I hereby release the screening physician, Hampton Roads Ultrasound and all other healthcare volunteers/employees and contractors 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 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
Acknowledgement - Receipt of Notice of HIPPA Agreement and Privacy Practices and Exam Descriptions and Release.*

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Surgical History:
Risk Factors*

Tobacco UseHigh Blood PressurePrevious stroke/TIADiabetesObesityFamily history of strokeHigh cholesterolHeart DiseaseFamily history of abdominal aorta aneurysmVascular surgeryExcessive alcohol useFamily history of cancerPrevious diagnosis of any type of cancerNone
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 visionAbnormal hot or cold sensitivityChest painPalpitationsShortness of breath at restAbnormal shortness of breath on exertionEasy bruisingSwollen lymph nodesHallucinationsConfusionNose bleedsNone
Screenings will occur at the following locations:

301 Goodwin Neck Rd. Yorktown VA 23692

and

5684 Mooretown, Williamsburg, VA 23188
Please choose the screening location you would like to attend and select ONE available date from ONE of the calendars below.*

301 Goodwin Neck Rd. Yorktown VA 236925684 Mooretown, WIlliamsburg, VA 23188
Comprehensive Screening Location 301 Goodwin Neck Rd. Yorktown VA 23692:
Comprehensive Screening Location: 5684 Mooretown, Williamsburg, VA 23188
If needed, Hampton Roads Ultrasound may share my result with my primary care physician.*

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Primary Care Physician's Name

First NameLast Name
I certify that all the information provided is accurate to the best of my ability, and I consent to the cardiovascular screening examinations.
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York County Fire and Life Safety Cardiovascular Disease and Cancer Screening