|
PrePregnancy Weight (lbs)
|
Age
|
|
Total Pregnancy
|
Full Term
|
|
Premature
|
Abortion Induced
|
|
Abortion Spontaneous
|
Ectopic
|
|
Multiple Births
|
Living
|
|
LMP
|
Certain on LMP
|
|
Normal Amount/Duration
|
Menses Monthly?
|
|
Frequency:
|
Menarche
|
|
Prior Menses Date
|
On BCP at Conception?
|
|
hCG+ Date
|
Menstrual Hx Comments
|
|
1 Past Pregnancy DATE
|
1 GA Weeks
|
|
1 Length of Labor (hrs)
|
1 Sex
• • •
|
|
1 Birth Weight (lbs)
|
1 Birth Weight (oz)
|
|
1 Type of Delivery
|
1 Anesthesia
|
|
1 Place of Delivery
|
1 Preterm Labor
|
|
1 Complications
• • •
|
1 Comments
|
|
2 Past Pregnancy DATE
|
2 GA Weeks
|
|
2 Length of Labor (hrs)
|
2 Sex
• • •
|
|
2 Birth Weight (lbs)
|
2 Birth Weight (oz)
|
|
2 Type Delivery
• • •
|
2 Anesthesia
|
|
2 Place of Delivery
|
2 Preterm Labor
|
|
2 Complications
• • •
|
2 Comments
|
|
3 Past Pregnancy DATE
|
3 GA Weeks
|
|
3 Length of Labor (hrs)
|
3 Sex
• • •
|
|
3 Birth Weight (Lbs)
|
3 Birth Weight (oz)
|
|
3 Type of Delivery
|
3 Anesthesia
• • •
|
|
3 Place of Delivery
|
3 Preterm Labor
|
|
3 Complications
• • •
|
3 Comments
|
|
4 Past Pregnancy DATE
|
4 GA Weeks
|
|
4 Length of Labor (hrs)
|
4 Sex
• • •
|
|
4 Birth Weight (lbs)
|
4 Birth Weight (oz)
|
|
4 Type of delivery
|
4 Anesthesia
|
|
4 Place of Delivery
|
4 Preterm Labor
|
|
4 Complications
• • •
|
4 Comments
|
|
5 Past Pregnancy DATE
|
5 GA Weeks
|
|
5 Length of Labor (hrs)
|
5 Sex
• • •
|
|
5 Birth Weight (lbs)
|
5 Birth Weight (oz)
|
|
5 Type of Delivery
|
5 Anesthesia
|
|
5 Place of Delivery
|
5 Preterm Labor
|
|
5 Complications
• • •
|
Comments
|
|
6 Past Pregnancy DATE
|
6 GA Weeks
|
|
6 Length of Labor (hrs)
|
6 Sex
• • •
|
|
6 Birth Weight (lbs)
|
Birth Weight (oz)
|
|
6 Type of Delivery
|
6 Anesthesia
|
|
6 Complications
• • •
|
6 Comments
|
|
|
|
|
1. Diabetes:
|
Comments
|
|
2. Hypertension
|
Comments
|
|
3. Heart Disease
|
Comments
|
|
4. Autoimmune Disorder
|
Comments
|
|
5. Kidney Disease/UTI
|
Comments
|
|
6. Neurologic/Epilepsy:
|
Comments
|
|
7. Pyschiatric
|
Comments
|
|
8. Depression/Postpartum Depress
|
Comments
|
|
9. Hepatitis/Liver Disease
|
Comments
|
|
10. Variscosities/Phlebitis
|
Comments
|
|
11. Thyroid Dysfunction
|
Comments
|
|
12. Trauma/Violence/Sexual Abuse
|
Comments
|
|
13. History of Blood Transfusion
|
Comments
|
|
14. Tobacco
|
Tobacco: AMT/DAY PREPREG
• • •
|
|
Tobacco: AMT/DAY PREG
• • •
|
Tobacco: # YEARS USE
|
|
15. Alcohol
|
Alcohol: AMT/DAY PREPREG
• • •
|
|
Alcohol: AMT/DAY PREG
• • •
|
Alcohol: # YEARS USE
|
|
16. Illicit/Recreational Drugs
|
Drugs: AMT/DAY PREPREG
|
|
Drugs: AMT/DAY PREG
|
Drugs: # YEARS USE
|
|
17. D (Rh) Sensitized
|
Comments
|
|
18. Pulmonary (TB, Asthma)
|
Comments
|
|
19. Seasonal Allergies
|
Comments
|
|
20. Drug/Latex Allergies
|
Comments
|
|
21. Breast
|
Comments
|
|
22. Gyn Surgery
|
Comments
|
|
23. Operations/Hospitalizations:
|
Year and Reason
|
|
24. Anesthetic Complications
|
Comments
|
|
25. History of Abnormal Pap
|
Comments
|
|
26. Uterine Anomaly/DES
|
Comments
|
|
27. Infertility
|
Comments
|
|
28. ART Treatment
|
Comments
|
|
29. Relevant Family History
|
Comments
|
|
30: Other
|
Medical History Comments
|
|
|
|
|
Symptoms Since LMP
• • •
|
Comments
|
|
|
|
|
1. Patients Age 35>= By EDD
|
2. Thalassemia Ita,Grk,Med,Asi
|
|
3. Neural Tube Defect
|
4. Congenital heart defect
|
|
5. Down Syndrome
|
6. Tay-Sachs (AshJew, Caj, Fre)
|
|
7. Canavan Disease (Ash Jew)
|
8. Familial Dsyautonomia (Jew)
|
|
9. Sickle Cell disease (African)
|
10. Hemophilia or blood dis
|
|
11. Muscular Dystrophy
|
12. Cystic Fibrosis
|
|
13. Huntington's Chorea
|
14. Mental/Retardation/Autism
|
|
14b. If yes, Fragile X?
|
15. Other gen/chrom disorder
|
|
16. Maternal Metabolic Disorder
|
17. Other Birth Defects
|
|
18. Recurrent Loss or Stillbirth
|
19. Medications
|
|
20. Any Other
|
Genetic Comments/Counseling
|
|
|
|
|
1. Live with TB or exposed?
|
2. Pt,FOB hx of Genital Herpes?
|
|
3. Rash, Virus since LMP?
|
4. Hepatitis B, C
• • •
|
|
5. History of STD
• • •
|
Infection History Comments
|
|
|
|
|
1. HEENT NORMAL
|
ABNORMAL
|
|
2. FUNDI NORMAL
|
ABNORMAL
|
|
3. TEETH NORMAL
|
ABNORMAL
|
|
4. THYROID NORMAL
|
ABNORMAL
|
|
5. BREASTS NORMAL
|
ABNORMAL
|
|
6. LUNGS NORMAL
|
ABNORMAL
|
|
7. HEART NORMAL
|
ABNORMAL
|
|
8. ABDOMEN NORMAL
|
ABNORMAL
|
|
9. EXTREMITIES NORMAL
|
ABNORMAL
|
|
10. SKIN NORMAL
|
ABNORMAL
|
|
11. LYMPH NODES NORMAL
|
ABNORMAL
|
|
12. VULVA NORMAL
|
ABNORMAL
• • •
|
|
13. VAGINA NORMAL
|
ABNORMAL
• • •
|
|
14. CERVIX NORMAL
|
ABNORMAL
• • •
|
|
UTERUS SIZE (WEEKS)
|
FIBROIDS
|
|
16. ADNEXA NORMAL
|
ABNORMAL
• • •
|
|
17. RECTUM NORMAL
|
ABNORMAL
|
|
18. DIAGONAL CONJUGATE
• • •
|
CM
|
|
19. SPINES
• • •
|
20. SACRUM
• • •
|
|
21. SUBPUBIC ARCH
• • •
|
22. GYNECOID PELVIC TYPE
|
|
Initial PE Comments
|
|
|
New Field
• • •
|
|
