There is an NG/OG/FT tube which is malpositioned   [Yes/No]

There is an unexpected radiopaque foreign body or incidental non-surgical foreign body in the abdomen or pelvis.   [Yes/No]

There are additional lines, tubes, catheters or drains in place (examples include chest tubes, mediastinal drains, rectal temperature probe, etc.).   [Yes/No]

There is dilatation with gas or fluid of multiple or diffuse loops of bowel.   [Yes/No]

​Both the small and large bowel are filled with air and/or fluid and may or may not be distended.   [Yes/No]

There is a paucity of gas in the abdomen.   [Yes/No]

There are centralized loops of small bowel with distention of the abdomen and pelvis.   [Yes/No]

There is organomegaly.   [Yes/No]

There are intra-abdominal calcifications.   [Yes/No]

There is free air present.   [Yes/No]

The visualized bones are abnormal.   [Yes/No]

Fluoroscopic examination of the chest shows pneumonia, atelectasis, or cardiomegaly.   [Yes/No]

The hemidiaphragmatic excursions are inequal and nonsynchronous.   [Yes/No]

The patient was given thin barium/water soluble contrast to drink via bottle/syringe/sippy cup/straw/cup. A total of---mL of thin barium/water soluble was used for this examination.   [Yes/No]

The exam is limited by patient motion or non-cooperativity.   [Yes/No]

The exam is limited by small or inadequate boluses/contrast intake.   [Yes/No]

The swallowing act is abnormal.   [Yes/No]

There is tracheal aspiration.    [Yes/No]

The course of the esophagus is abnormal.   [Yes/No]

The caliber of the esophagus is abnormal.   [Yes/No]

There is stenosis of the upper/mid/distal esophagus.   [Yes/No]

There is dilatation of the upper/mid/distal esophagus.   [Yes/No]

There is a tracheoesophageal fistula present.    [Yes/No]

There is a filling defect.    [Yes/No]

There is dysmotility of the esophagus.   [Yes/No]

There is extrinsic mass effect.   [Yes/No]

There is a vascular ring.   [Yes/No]

The stomach does not fill readily.   [Yes/No]

If the contrast is instilled via NG tube/gastrostomy tube/orogastric tube: There is abnormal contrast opacification of the stomach.   [Yes/No]

The stomach empties abnormally.   [Yes/No]

There is gastric outlet obstruction.   [Yes/No]

The duodenal C-loop is abnormal in size.   [Yes/No]

The location of the ligament of Treitz is abnormal.   [Yes/No]

The proximal jejunum is dilated.    [Yes/No]

There is gastroesophageal reflux observed to the upper/mid/distal esophagus.   [Yes/No]

The reflux does not clear quickly.   [Yes/No]