Gastric Ultrasound Assessment Form
Complete this form to record and interpret findings from a gastric ultrasound examination.
Patient Initials
*
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Indication for Ultrasound
*
Preoperative assessment
Aspiration risk evaluation
Gastric pathology investigation
Other
Fasting Status
*
≥8 hours fasting
4-8 hours fasting
<4 hours fasting
Unknown
Patient Position During Scan
*
Supine
Right lateral decubitus
Both positions
Image Quality Assessment
*
1
2
3
4
5
Gastric Content Type
*
Empty
Clear fluid
Thick fluid
Solid
Other
Estimated Gastric Volume (mL)
*
Interpretation / Aspiration Risk
*
Low risk
Intermediate risk
High risk
Assessor Name or ID
*
Submit Assessment
Should be Empty: