Cornerstone Clinic & Medical Centre

No 3, Korede Quarters, Kabba, Kogi State.

Department of Radiology & Imaging

07035070333, 07072437781

Patient Information

Patient Name

Age

Date

Referring Hospital

Indication

Referred By

Comprehensive Fetal Assessment

Number of Fetuses

Fetal Lie

Viability

FHR (bpm)

Last Menstrual Period (LMP)

Expected Date of Delivery (EDD)

Gestational Age (GA)

BPD (mm)

Femur Length (mm)

AC (mm)

Fetal Sex

Estimated Fetal Weight (enter in grams)

Fetal Anomalies

Placental Location

Amniotic Fluid (Liquor)

Additional Comments

Clinical Conclusion

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