A visitor to SoCalMDS.com has filled out the NCV-EMG Referral Form at http://www.socalmds.com/ncvemg.php

PATIENT INFORMATION:
Full name: #name#
phone: #phone#
Email address: #email#
MR# (may be blank): #mr#

ADDRESS:
#street#
#addresscont#
#citystate#

EMG REPORT:
EMG report sent to: #emgsentradio#
Refer phone: #referphone#
Refer fax (may be blank): #referfax#

PARTINENT PMHx:
Compaint: #complaint#
Duration: #duration#
Extremity: #extremity#
Side of body: #side#

Previous EMG?: #previousemg#
When and where was previous EMG? (may be blank): #whenwhyemg#

Brief Neurological Exam Below (may be blank):
#examinfo#

Evaluate for: #evaluate#
If they selected "other" under evaluate for (may be blank): #evaluateother#

Thanks for filling out Southern California Movement Disorder Specialists\' NCV-EMG Referral form. One of our experts will get in touch with you via email or phone if we have any questions. If you have any other questions or comments, feel free to get a hold of us: http://www.SoCalMDS.com/contact.php

- Thanks!

Patient Information

First & Last Name

MR#

Email Address

Phone Number

Address

Street

City, State

EMG Report

EMG Report sent to:

Referring Provider Other Provider error for emgsentradio

Their Phone Number:

Their Fax Number:

Partinent PMHx

complaint

Numbness/Paresthesias/Tingling Pain Weakness/Fatique Increase CK, possible myopathy error for complaint

Extremity Affected

Arm Leg Face, Tongue Diaphragm/Trunk/Adbomen error for extremity

Previous EMG?

Brief neurological exam below:

Duration of Symptoms

Note: It can take >3 weeks to fully develop EMG abnormalities after nerve injury.

Side of Body Effected

Left Right error for side

Helpful Info

On Warfarin or Herparin Platelets <30.000 Latex Allergy error for moreinfo

Evaluate for:

Carpal Tunnel Syndrome Cervical Radiculopathy Lumbar Radiculopathy Generalized Peripheral Neuropathy Ulnar Neuropathy Myopathy Brachial Plexopathy Myasthenia Gravis / Lambert Eaton Other error for evaluate

If "Other" selected, describe:

Download Form

Nerve Conduction & EMG

Referral Form (PDF)

About EMGs and Nerve Condition Studies

Muscles are controlled by electrical impulses from the body's nerves. When there is a problem with nerve function muscles can behave abnormally, such as twitching or paralysis. Pain and numbness are also possibilities and should be checked out. There are tests available to help determine the cause of such problems such as an EMG (electromyogram) which records the electrical activity of muscles. This test involves the insertion of a needle electrode into a muscle. There are also nerve conduction studies, which can find nerve damage to areas in the peripheral nervous system. In this case, several electrodes are placed so that when electrical pulses are given, the speed of response can be measured.

About the Tests

The EMG may seem intimidating, but it is quite safe—you won't feel more than a poke, and the needles are sterile. If you are undergoing either of these tests, it is important your doctor know if you are taking any medication or blood thinners, and if you have a pacemaker. Also avoid consuming anything containing caffeine for a few hours before the test.

Phone: (626) 792-MOVE
Fax: (626) 793-LISK
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