Altamonte Springs: 385 Center Pointe Circle • Suite 1319 ...
PELVIC ULTRASOUND WORKSHEET
Transvaginal Imaging Performed
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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
................
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