CONSULT FOR _____

Patient Name:                        _____

Medical Record#:                 _____

Date of Clinic Visit:              _____

Date of Birth:                        _____

Referred by:                          _____

Physician:                              _____

Dear Dr. _____:

Thank you for the referral of _____ to the Interventional Radiology Clinic today.  I met with _____ as well as _____.  We discussed possible _____ of _____.

HISTORY OF PRESENT ILLNESS:   _____

PAST MEDICAL HISTORY:  _____

PAST SURGICAL HISTORY:  _____

FAMILY HISTORY:  _____

SOCIAL HISTORY:  _____

ALLERGIES:  _____

MEDICATIONS:  _____

REVIEW OF SYMPTOMS:

                Please see patient information form on file.  (+) _____.

PHYSICAL EXAM:

Blood Pressure:  _____     Temperature:  _____         Pulse:  _____       Respirations:  _____

Height:  _____                     Weight:  _____

General:  Alert and oriented x 3 with no active distress.  

Neuro: 

Heart: Regular rate and rhythm.

Lungs:  Clear to auscultation.

Abdomen:  _____.

Extremities:  No peripheral edema.

LAB:

WBC _____ k/cumm, Hemoglobin _____ g/dl, Hematocrit _____%, Platelets _____ k/cumm

INR _____, PT _____sec, PTT _____sec

BUN _____ mg/dl, Creatinine _____ mg/dl

Total Bilirubin _____ mg/dl, Albumin _____ g/dl, Alkaline Phosphatase _____ U/l

AST _____ U/l, ALT _____ U/l, GGT _____ U/l, LDH _____ U/l, Protein _____ g/dl.

IMAGING STUDIES:  _____

ASSESSMENT:  _____

PLAN:  _____

                Thank you again for referring _____ to me for possible _____.  If you have any questions or concerns, please do not hesitate to call me.

Sincerely,

 _______ Professor, Department of Radiology

Section of Vascular and Interventional Radiology

Indiana University Hospital, Room 0279

550 North University Boulevard

Indianapolis, IN  46202-5253

Tel:         317-274-1840

Fax:         317-278-7793

Email:      ___