Name and Address of Ultrasound Unit


Patient Name

Name Plate if Available

Date of study

Address

Identification

Referring MD

Copies to MD

LMP:

EDD (by dates):

EDD by U/S (if known):

Biometry:

Biparietal Diameter (BPD):

mm

Weeks: Days:

+/- 2SD:
Percentile:

Head Circumference (HC):

mm

Weeks: Days:

+/- 2SD:
Percentile:

Abdominal Circumference (AC):

mm

Weeks: Days:

+/- 2SD:
Percentile:

Femur Length (FL):

mm

Weeks: Days:

+/- 2SD:
Percentile:

Average Ultrasound Gestation Age:

 

Weeks: Days:

+/- 2SD:
Percentile:

Estimated Fetal Weight (>25 weeks):

 

Gm:

+/- 2SD:
Percentile:

Amniotic Fluid Volume:


(if less than 30 weeks):

 

Comments:

+/- 2SD:
Percentile:

Amniotic Fluid Index:
(AFI > 28-30 weeks)

cm

3cm Vertical Fluid Pocket: Yes  No

 

Ultrasound EDC (if gestation age is >21 weeks):

 

Comments:

+/- 2SD:
Percentile:

Growth Appropriate for Gestational Age
(based on menstrual data/early scan):

 

Yes  No  Unknown

+/- 2SD:
Percentile:


Fetal Number:

Fetal Heart Rate: BPM

Fetal Presentation:

Fetal Heart Rhythm:




Fetal Anatomy

Normal

Not Well Seen

Abnormal

Comments

Head

Ventricles

Cerebellum

Cisterna Magna

Nuchal Fold (<20 weeks)

Face (including profile & lips):

Spine (Normal in two planes)

Heart (4 chamber view including its position in the thoracic cavity)

Kidney

Right

Left

Stomach (on L side)

Urinary Bladder

Limbs

Umbilical Cord

3 Vessels

Fetal Insertion

Placenta Location:
(including relationship to the internal cervical if width is within 2cm):

Cervical Length:

cm ( if <2.5cm)

Biophysical Profile Components:

Fetal Breathing

/2

Fetal Tone

/2

Fetal Movement

/2

AFV

/2

Biophysical Profile Score =

/8




Comments / Conclusions








Sonographer: ____________________

Sonologist: ____________________

Name & Signature

Name & Signature