SONOGRAPHER WORKSHEET - SAMPLE Surname Sonographer Observations only. This is NOT a diagnosis by a medical practitioner Address Given Name DD – MON – YY Exam Date: Phone number Clinical Information: Personal Health Number LMP: DD-MON-YY = DD-MON-YY 1st US on: CRL = Gestational age today = Number of Fetuses: days ☐ Uncertain wks mm = days Based wks Membrane: ☐ Fetus A ☐ Fetus B ☐ Fetus C LMP Physician / Midwife Name G T P days wks on: Last Scan Date: DD-MON-YY Chorionicity / Amnionicity: EV: ☐ Yes ☐ No EV# FHR: Placenta: ☐ Yes ☐ No Previa: cmDVP: Mean Sac Diameter: mm cm = BPM Cervix (less than 32 wks): wksNT: Less than 10% L ☐ No previous scan Fetal Position: AFI: A mm cm FMF #: 10 – 50% Greater than 90% 50 – 90% (For gestational age today) CRL BPD HC AC FL mm = 50% for wks mm = 50% for wks mm = 50% for wks mm = 50% for wks mm = 50% for wks Est. Fetal Age: days ± wks wks Est. Fetal Weight: Est. Fetal age based on: ☐ LMP ☐ 1st US ☐ Conception ☐ IVF ☐ Today’s Scan EDD: gm DD-MON-YY Cerebral Ventricles Abd. Cord Ins. Cisterna M. / Cerebellum Heart (axis) 4C ☐ Markers Not Assessed FETAL SOFT MARKERS ☐ ☐ None seen Bi / ☐ Uni lateral mm Choroid Plexus Cyst (CPC) CSP Heart (SAX or Outflows) Cardiac Echogenic focus ☐ None seen ☐ Present Choroid Plexus Stomach Nuchal fold (thickness) ☐ Normal Face (Lips / Orbits) Kidneys Echogenic Bowel ☐ Normal ☐ Grade 2 ☐ Grade 3 Spine Bladder Pyelectasis ☐ None mm L mm R mm 4 Limbs 3VC Genitalia: ☐ M ☐ F ☐ not determined Expand the exam as required. Document and measure, if appropriate, abnormal findings and structures not well seen. Comments: Date DD – MON – YY © Perinatal Services BC AUGUST 2012 Sonographer Initials