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ACOG Form A: ANTEPARTUM RECORD
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GFPAL (x-x-x-x-x)
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GFPAL Comments (Twins, Ectopics)
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LMP:
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LMP Certainty:
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EDC:
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EDC Methodology:
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FOB's Name:
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FOB Relationship:
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PREG'Y HX (Date,GA,Type,Gen,Wt):
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PRENATAL MEDICAL HISTORY:
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Diabetes? (Who, Comments):
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Hypertension? (Who, Comments):
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Heart Disease? (Who, Comments):
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Autoimmunity? (Who, Comments):
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Neuro Disease? (Who, Comments):.
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Kidney Disease? (Who, Comments):
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PP Depression? (Who, Comments):
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Psych Disease?(Who, Comments):
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Vascular Disease?(Who, Comments)
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Liver Disease? (Who, Comments):
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Thyroid Disease?(Who, Comments):
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Trauma/Violence?(Who,Comments):
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Breast Disease?(Who, Comments):
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Pulmonary Dis?(Who, Comments):
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Thrombophilia?
• • •
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D (Rh) Sensitization?
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Hx Blood Transfusion?
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Seasonal Allergies?
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GYN Surgery?
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Drug/Latex Allergy?
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Anesthetic Complications?
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Other Surgery/Hospitalizations?
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Uterine/Cervical Anomalies?
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Hx of Abnormal Pap?(Grade/Date):
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Relevant Family Hx?
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Infertility/ART Rx?
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Other Hx/Issues?
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ACOG Form B: ANTEPARTUM RECORD
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>35yo at EDD?
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Thalassemia (Medit/Greek/Asian)?
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Neural Tube Defect? (Comments):
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Congen Heart Defect? (Comments):
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Trisomy/Aneuploidy?(Comments):
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Tay-Sachs?(Jew/Cajun/FrCanada):
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Canavan Disease?(Ashkenazi):
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Familial Dysautonomia(Ashkenazi)
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Sickle Cell Dis/Tr? (Who,Comm):
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Hemophilia/Blood Disorder?
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Muscular Dystrophy? (Comments):
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Cystic Fibrosis? (Comments):
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Huntington's Chorea?(Comments):
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Ment Retard'n/Autism/Frag X?
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Oth Genetic/Chromosomal Disorder
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Recurrent Pregnancy Loss?
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Meds/Drugs/Exposure since LMP?
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Other Teratogenic Exposure?
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Live w TB Pt. or Exposed to TB?
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Pt/Prtnr w Hx of Genital Herpes?
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Rash/Viral Illness since LMP?
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Hepatitis Hx or Exposure?
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Hx of STDs? (Comments):
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Other? (Comments):
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INITIAL PRENATAL PHYSICAL EXAM:
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HEENT: Normal?
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HEENT: Abnormal?
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TEETH: Normal?
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TEETH: Abnormal?
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THYROID: Normal?
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THYROID Abnormal?
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BREASTS: Normal?
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BREASTS: Abnormal?
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LUNGS: Normal?
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LUNGS: Abnormal?
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HEART: Normal?
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HEART: Abnormal?
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ABDOMEN: Normal?
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ABDOMEN: Abnormal?
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EXTREMITIES: Normal?
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EXTREMITIES: Abnormal?
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SKIN: Normal?
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SKIN: Abnormal?
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LYMPH NODES: Normal?
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LYMPH NODES: Abnormal?
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