Documentation of Ultrasound Form

Tape Sonogram Picture(s) here
INDICATIONS:

Prior to Medication abortion

on OCPs in last 3 months
uncertain LMP
9 weeks or greater by LMP
breastfeeding
irregular cycles/cycle length>35d
cost/logistical issues
teaching
size-date discrepancy

Post Medication abortion
Pre Aspiration abortion
Post Aspiration abortion

Prenatal dating

on OCPs in last 3 months
uncertain LMP
breastfeeding
irregular cycles/cycle length >35d
1st tri bleeding/threatened abortion
teaching
size-date discrepancy

Other ___________________________

        _______________________________

FINDINGS:

GS  ___________mm
CRL ___________mm
YS
FH
Other ___________________________

        _______________________________

GS:
__mm+30 =__Gestational age (days)

CRL:
__mm+42 =__Gestational age (days)

Scan

  ___________________________________
  Provider Signature

  ___________________________________
  Date

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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.