Altamonte Springs: 385 Center Pointe Circle • Suite 1319 ...



PELVIC ULTRASOUND WORKSHEET

Transvaginal Imaging Performed

[pic]

Cul-de-sac Fluid: TRACE MINIMUM MODERATE SEVERE

Comments: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

-----------------------

Name:____________________________________________ Date:_____/_____/____ ID:_________________

DOB: _____/______/______ Age:______ Referring Physician:____________________________________

Indications:__________________________________________________________________ Tech:_________

Height: _____________ Weight:______________ LMP ____/____/____ G____P____M____A____

HRT/BCP: YES / NO_______________________________________________________________

Previous Surgery:_________________________________________________________________

Uterus: ______ X_____ X______cm Nabothian Cysts

Endometrium: ________cm

Masses/Fibroids:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____

Right Ovary: ______ X_____ X_____ cm

( Simple Cyst(s) ( Complex Cyst(s) ( Mass ( Other

Left Ovary: ______ X_____ X_____ cm

( Simple Cyst(s) ( Complex Cyst(s) ( Mass ( Other

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download