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):
Biparietal Diameter (BPD):
mm
Weeks: Days:
+/- 2SD: Percentile:
Head Circumference (HC):
Abdominal Circumference (AC):
Femur Length (FL):
Average Ultrasound Gestation Age:
Estimated Fetal Weight (>25 weeks):
Gm:
Amniotic Fluid Volume:
(if less than 30 weeks):
Comments:
Amniotic Fluid Index:(AFI > 28-30 weeks)
cm
3cm Vertical Fluid Pocket: Yes No
Ultrasound EDC (if gestation age is >21 weeks):
Growth Appropriate for Gestational Age(based on menstrual data/early scan):
Yes No Unknown
Fetal Number:
Fetal Heart Rate: BPM
Fetal Presentation:
Fetal Heart Rhythm: Regular Irregular
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)
Fetal Breathing
/2
Fetal Tone
Fetal Movement
AFV
/8
Name & Signature