Pelvic Ultrasound Report Form
Use this form to record a pelvic ultrasound report, including exam details, indication, technique, findings, and impression.
Patient and Exam Details
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex at Birth
Female
Male
Intersex
Prefer not to say
Ordering Clinician / Referring Provider
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exam Time
Hour Minutes
AM
PM
AM/PM Option
Clinical Indication and Technique
Clinical indication / reason for exam
*
Ultrasound approach used
*
Transabdominal
Transvaginal
Both
Technique notes or limitations
Report Findings and Impression
Uterus Findings
Endometrium Findings
Adnexal and Free Fluid Findings
Right Ovary Findings
Left Ovary Findings
Impression / Summary
Submit
Should be Empty: