First Trimester Ultrasound Report
Complete this form to document a first trimester ultrasound examination, including pregnancy dating, findings, impression, and follow-up notes.
Patient and Exam Details
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record / Chart Number
Referring Clinician Name
First Name
Last Name
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gestational Age by Last Menstrual Period (weeks)
Obstetric History and Pregnancy Information
Last Menstrual Period Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated Gestational Age (weeks)
Number of Pregnancies
Number of Births
Dating Status
Known
Uncertain
Ultrasound Findings
Number of Gestational Sacs
*
Number of Embryos/Fetuses
*
Fetal Cardiac Activity
*
Present
Absent
Not Assessed
Crown-Rump Length (mm)
Yolk Sac Present
Yes
No
Not Assessed
Mean Sac Diameter (mm)
Uterine Findings
Adnexal Findings
Free Fluid or Other Notable Observations
Impression and Follow-up
Impression / Summary
*
Viability Assessment
*
Please Select
Viable intrauterine pregnancy
Pregnancy of uncertain viability
Non-viable pregnancy
Not assessable
Other
Dating Assessment
*
Please Select
Consistent with dates
Measuring ahead
Measuring behind
Unable to assess dating
Other
Recommended Follow-up / Additional Comments
Submit Report
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