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Reproductive Health Access Project
 
 
Documentation of Ultrasound Form

Tape Sonogram Picture(s) here

INDICATIONS:

Prior to Medication abortion

hormonal contraception (Past 3m)
uncertain LMP
irregular cycles/cycle length>35d
cost/logistical issues
teaching
size-date discrepancy
IUD at follow up
   bleeding
   8 weeks or greater by LMP

Post Medication abortion
Pre Aspiration abortion
Post Aspiration abortion

Prenatal

hormonal contraception (Past 3m)
uncertain LMP
breastfeeding
irregular cycles/cycle length >35d
1st tri bleeding/threatened abortion
teaching
size-dates discrepancy

IUD localization
Other ___________________________

FINDINGS:

Gestational Sac ____________mm (MSD)
CRL___________mm
Yolk Sac
Fetal Heart
Other ___________________________

 

GS: ______ mm+30 = _____ Gestational age (days)

CRL: ______ mm+42 = _____ Gestational age (days)

Dating by Hadlock: __________________________
For Pregnancy dating:
1st Tri, use crl + 42 until crl = 25, after crl > 25 use hadlock

EDD __________________________

 

Scan

  ___________________________________
  Provider Signature

  ___________________________________
  Date

DOWNLOAD PDF:
ENGLISH

DOWNLOAD WORD DOCUMENT:
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These forms are not intended to provide legal, medical or other professional advice. They are not a substitute for consultation with a healthcare provider or for independent judgment by healthcare providers or other professionals regarding individual conditions and situations.
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