Gynecologic Ultrasound Report - PSOT
Medicos Family Medicine Obstetrics
Gynecologic Ultrasound Report
Method of Advanced Family Medicine Specialists ()
February 27, 2001
Name:_____________________________ ID#:_____________________ Date:___________________
DOB:__________________ Age:_____________ Physician:__________________________________
MEDICAL HISTORY
|REASON FOR SCAN: |
|LMP: |WT: |HT: |G: |P: |
|Periods Regular Yes No |Pregnancy Test Done Yes No |IUD Present Yes No |
|Previous Pelvic Surgery: |
RESULTS
|Transabdominal Scan Yes No |Transvaginal Scan Yes No |
|Uterus |Normal |Abnormal |Measurements | X X |
|Right Ovary |Normal |Abnormal |Measurements | X X |
|Left Ovary |Normal |Abnormal |Measurements | X X |
|Cul de sac |Normal |Abnormal |Fluid? |No Yes |Amount: |
|Mass (Describe): |
Comments/Plan: __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Sonographer:________________________ Supervising Physician:_____________________________
02/27/01/dww
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