|
|
Referred By:
|
|
Primary Care Provider/Group
|
Address:
|
|
Final EDD:
|
Amniocentesis
|
|
Occupation
|
Education: (Last Grade Completed)
|
|
Partner
|
Phone
|
|
Father Of Baby:
|
Phone
|
|
Total Preg:
|
Full Term
|
|
Premature:
|
Ab, Induced:
|
|
Ab, Spontaneous:
|
Ectopics:
|
|
Multiple Births
|
Living:
|
|
Menstrual History
|
|
|
Lmp
• • •
|
Comments
|
|
Duration:
|
Frequency:
|
|
Prior Menses (Date)
|
Contraception at conception
|
|
Menarche: (Age onset)
|
Hcg +
|
|
Past Pregnancies (Last Five)
|
|
|
1st child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight (lb)
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
2nd Child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
3rd Child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
4th Child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
5th Child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
6th Child
|
Date: Month/Year
|
|
Length of Labor
|
GA Weeks
|
|
Sex
|
Birth Weight
|
|
Anes
|
Type of Delivery
|
|
Breastfeeding Duration
|
Place Of Delivery
|
|
Comments/Complications
|
Lactation consult needed?
|
|
Medical History
|
|
|
Drug/Latex Allergies/ Reactions
|
|
|
Allergies (Food, Seasonal, Environmental)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Neurologic/Epilepsy
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Thyroid Dysfunction
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Breast Disease/Breast Surgery
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Pulmonary (TB, Asthma)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Heart Disease
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Hypertension
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Cancer
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Hematologic Disorders
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Anemia
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Gastrointestinal Disorders
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Hepatitis/Liver Disease
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Kidney Disease/UTI
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Deep Vein Thrombosis
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Diabetes (Type 1 Or Type 2)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Gestational Diabetes
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Autoimmune Disorders
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Dermatologic Disorders
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Operations/Hospitalizations (Year & Reason)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Gyn Surgery (Year & Reason)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Anesthetic Complications
|
Detail Positive Remarks (Include Date & Treatment)
|
|
History Of Blood Transfusions
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Infertility
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Art (IVF Or FET)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
History of Abnormal Pap
|
Detail Positive Remarks (Include Date & Treatment)
|
|
History of STI
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Psychiatric Illness
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Depression/Postpartum Depression
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Trauma/Violence
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Tobacco (Smoked, Chewed, ENDS, Vaped) (AMT/Day)
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Preg
|
Prepreg
|
|
Alcohol (AMT/Wk)
|
# Years use
|
|
Preg
|
Prepreg
|
|
Drug Use (Including Opioids) (Uses/Wk)
|
# Years use
|
|
Preg
|
Prepreg
|
|
Polycystic Ovary Syndrome
|
# Years use
|
|
Other
|
Detail Positive Remarks (Include Date & Treatment)
|
|
COMMENTS:
|
Detail Positive Remarks (Include Date & Treatment)
|
|
Genetic Screening
|
|
|
Congenital Heart Defect
• • •
|
|
|
Neural Tube Defect
• • •
|
Relationship
|
|
Hemoglobinopathy Or Carrier
• • •
|
Relationship
|
|
Cystic Fibrosis
• • •
|
Relationship
|
|
Chromosome Abnormality
• • •
|
Relationship
|
|
Tay–Sachs
• • •
|
Relationship
|
|
Hemophilia
• • •
|
Relationship
|
|
Intellectual Disability/Autism
• • •
|
Relationship
|
|
Recurrent Pregnancy Loss/Stillbirth
• • •
|
Relationship
|
|
Other Structural Birth Defect
• • •
|
Relationship
|
|
Other Genetic Disease (eg, PKU, Metabolic Disease, Muscular Dystrophy)
• • •
|
Relationship
|
|
Teratogen Exposures Since LMP/Conception
|
Relationship
|
|
Prescription Medications
|
|
|
Over The Counter Medications
|
Details/Date
|
|
Alcohol
|
Details/Date
|
|
Illicit Drugs
|
Details/Date
|
|
Maternal Diabetes
|
Details/Date
|
|
Other
|
Details/Date
|
|
Uterine Anomaly/DES
|
|
|
COMMENTS/COUNSELING
|
Details/Date
|
|
Infection History
|
|
|
Live with Someone with TB or Exposed to TB
|
|
|
Rash or Viral Illness Since Last Menstrual Period
|
Patient or Partner has History of Genital Herpes
|
|
History of STIS:
• • •
|
Prior GBS-Infected Child
|
|
History Of Hepatitis
|
HIV Infection
|
|
Other (See Comments)
|
Recent Travel History Outside Of Country
|
|
COMMENTS:
|
|
|
Immunizations
|
|
|
TDAP (Each pregnancy; between 27–36 weeks)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Influenza† (Each pregnancy as soon as vaccine is available)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Varicella†
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
MMR (Rubellacontaining vaccine)†
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
HPV
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Hepatitis A (When Indicated)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Hepatitis B (When Indicated)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Meningococcal (When Indicated)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Pneumococcal (When Indicated)
|
|
|
If no, Vaccine Indicated?
|
If yes, Date
|
|
Initial Physical Examination
|
|
|
Date:
|
|
|
BP/Prepregnancy Weight:
|
|
|
BMI:
|
Height
|
|
Heent
|
|
|
Thyroid
|
Teeth
|
|
Lungs
|
Breasts
|
|
Abdomen
|
Heart
|
|
Skin
|
Extremities
|
|
Vulva
|
Lymph Nodes
|
|
Cervix
|
Vagina
|
|
Uterus Size: Weeks?
|
|
|
Adnexa
|
Uterus Size: Fibroids
|
|
Clinical Pelvimetry
|
Rectum
|
|
COMMENTS (Number and explain abnormals):
|
|
|
|
|
|
EXAM BY:
|
|
|
Drug Allergy:
|
|
|
Postpartum Contraception Method:
|
|
|
Is Blood Transfusion Acceptable?
|
Latex Allergy
|
|
Problems
|
Counseled About LARC?
|
|
Resolved?
|
Antepartum Anesthesia Consult Planned?
|
|
Problems
|
Plans
|
|
Resolved?
|
|
|
Problems
|
Plans
|
|
Resolved?
|
|
|
Problems
|
Plans
|
|
Resolved?
|
|
|
Problems
|
Plans
|
|
Resolved?
|
|
|
|
Plans
|
|
Medication List
|
|
|
Stop Date
|
|
|
Medication List
|
Start Date
|
|
Stop Date
|
|
|
Medication List
|
Start Date
|
|
Stop Date
|
|
|
Medication List
|
Start Date
|
|
Stop Date
|
|
|
Medication List
|
Start Date
|
|
Stop Date
|
|
|
EDD Confirmation
|
Start Date
|
|
Lmp:
|
|
|
Initial Exam:
|
|
|
Ultrasonography:
|
EDD
|
|
Final Edd:
|
EDD
|
|
Initiated By:
|
EDD
|
|
Pregnancy Weight Gain
|
IVF Transfer:
|
|
Prepregnancy Weight
|
|
|
BMI
|
|
|
Recommended Weight Gain
|
Height
|
|
|
Estimated Weight Gain
|
|
Prepregnancy Weight
|
|
|
|
|
|
Date
|
BMI
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Date
|
Comments:
|
|
Weight
|
|
|
Urine (Albumin/Glucose)
|
Weeks Gest. (Best Est.)
|
|
Fetal Movement
|
Blood Pressure
|
|
FHR
|
Pain Scale
|
|
Presentation
|
Preterm Labor Signs/Symptoms
|
|
Cervix Examination (DIL./EFF. STA)
|
Fundal Height (CM)/EFW
|
|
Provider (Initials)
|
Edema
|
|
|
Next Appointment
|
|
Laboratory and Screening Tests
|
Comments:
|
|
Blood Type
|
|
|
Date
|
|
|
Reviewed
|
|
|
D (Rh) Type
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Antibody Screen
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Complete Blood Count
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
HCT/HGB:
|
|
|
MCV:
|
|
|
Reviewed
|
g/dL
|
|
VDRL/RPR (Syphilis)
|
PLT:
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Urine Culture/Screen
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
HBsAg
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
HIV Testing
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Chlamydia (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Gonorrhea (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Rubella Immunity
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Other:
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Supplemental Labs
|
Result
|
|
Hemoglobin Electrophoresis
|
Comments/Additional Labs
|
|
Date
|
|
|
Reviewed
|
|
|
PPD/Quanta (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Pap Test (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
HPV (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Early Diabetes Screen (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Varicella Immunity (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Cystic Fibrosis
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Spinal Muscular Atrophy
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Fragile X
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Tay–Sachs
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Canavan Disease
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Familial Dysautonomia
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Genetic Screening Tests (See Form B)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Other:
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
8–20-Week Aneuploidy Screening
|
Result
|
|
Aneuploidy Screening Offered
|
Comments/Additional Labs
|
|
Date Test Performed
|
|
|
Reviewed
|
|
|
1st Trimester Aneuploidy Screening
|
Result
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
2nd Trimester Serum Screening
|
Result
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Integrated Screening
|
Result
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Result
|
|
|
Cell-Free DNA
|
Result
|
|
Date Test Performed
|
Reviewed
|
|
Reviewed
|
|
|
CVS
|
Result
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Amniocentesis
|
Karyotype: 46,XX Or 46,XY/Other
|
|
Amniocentesis
|
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Amniotic Fluid (AFP)
|
Karyotype: 46,XX Or 46,XY/Other
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Other:
|
Result
|
|
Date Test Performed
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Late Pregnancy Labs and Screening
|
Result
|
|
Tdap Vaccination (Every Pregnancy; 27–36 Weeks)
|
Comments/Additional Labs
|
|
Date
|
|
|
Reviewed
|
|
|
Complete Blood Count
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
HCT/HGB:
|
|
|
MCV:
|
|
|
Reviewed
|
g/dL
|
|
Diabetes Screen (24–28 Weeks)
|
PLT:
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
GTT (If Screen Abnormal)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
D (Rh) Antibody Screen (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Anti-D Immune Globulin (Rhlg) Given (28 Wks Or Greater) (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Complete Blood Count
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
HCT/HGB:
|
|
|
MCV:
|
|
|
Reviewed
|
g/dL
|
|
Ultrasonography (18–24 Weeks) (When Indicated)
|
PLT:
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
HIV (When Indicated)*
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
VDRL/RPR (Syphilis) (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Gonorrhea (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Chlamydia (When Indicated)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Group B Strep (35–37 Weeks)
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Resistance Testing If Penicillin Allergic
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Other:
|
Result
|
|
Date
|
Comments/Additional Labs
|
|
Reviewed
|
|
|
Comments:
|
Result
|
|
Plans/Education
|
Comments/Additional Labs
|
|
First Trimester-Psychosocial Screening
|
|
|
Desire For Pregnancy
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Depression / Anxiety (Should Be Performed At Least Once During Perinatal Period)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Alcohol
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Tobacco (Smoked, Chewed, ENDS, Vaped) Cessation Counseling (Ask, Advise, Assess, Assist, And Arrange)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Illicit/Recreational Drugs/Substance Use (Parents, Partner, Past, Present)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Intimate Partner Violence
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Barriers To Care
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Unstable Housing
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Communication Barriers
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Nutrition
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Wic Referral
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Environmental/Work Hazards
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Anticipatory Guidance
|
Referral
|
|
Anticipated Course Of Prenatal Care
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Nutrition Counseling; Special Diet; Dietary Precautions (Mercury, Listeriosis)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Weight Gain Counseling
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Toxoplasmosis Precautions (Cats/Raw Meat)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Use Of Any Medications (Including Supplements, Vitamins, Herbs, Or Otc Drugs)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Sexual Activity
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Exercise
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Dental Care/Refer to Dentist
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Avoidance Of Saunas Or Hot Tubs
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Seat Belt Use
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Childbirth Classes/Hospital Facilities
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Breastfeeding
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Fetal Testing
|
Referral
|
|
Indications For Ultrasonography
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Screening For Aneuploidy
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Second Trimester
|
Referral
|
|
Anticipatory Guidance
|
|
|
Signs And Symptoms Of Preterm Labor
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Selecting A Newborn Care Provider
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Reproductive Life Planning & Contraception
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Postpartum Care Planning
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Psychosocial Screening
|
Referral
|
|
Tobacco (Smoked, Chewed, ENDS, Vaped) Cessation Counseling (Ask, Advise, Assess, Assist, And Arrange)
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Depression / Anxiety (Should Be Performed At Least Once During Perinatal Period)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Intimate Partner Violence
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Third Trimester
|
Referral
|
|
Birth Preferences
|
|
|
Pain Management Plans
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Trial Of Labor After Cesarean Counseling
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments
• • •
|
Date
|
|
Labor Support Person(S)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Immediate Postpartum Larc
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments
• • •
|
Date
|
|
Circumcision Preference
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments
|
Date
|
|
Infant Feeding Intention
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments
• • •
|
Date
|
|
Anticipatory Guidance
|
Referral
|
|
Fetal Movement Monitoring
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Signs And Symptoms Of Preeclampsia
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Labor Signs
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Cervical Ripening/Labor Induction Counseling
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Postterm Counseling
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Infant Feeding
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Newborn Education (Newborn Screening, Immunizations, Jaundice, SIDS/Safe Sleeping Position, Car Seat)
|
Date
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Family Medical Leave Or Disability Forms
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Postpartum Depression
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Psychosocial Screening
|
Referral
|
|
Tobacco (Smoked, Chewed, ENDS, Vaped) Cessation Counseling (Ask, Advise, Assess, Assist, And Arrange)
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Depression / Anxiety (Should Be Performed At Least Once During Perinatal Period)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Intimate Partner Violence
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Postpartum
|
Referral
|
|
Screening
|
|
|
Depression / Anxiety (Should Be Performed At Least Once During Perinatal Period)
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Infant Feeding Problems
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Birth Experience
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Glucose Screen (If Gdm)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Anticipatory Guidance
|
Referral
|
|
Infant Feeding
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Pelvic Muscle Exercise/Kegel
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Return To Work / Milk Expression
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Weight Retention
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Optimal Birth Spacing
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Postpartum Sexuality
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Exercise
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Nutrition
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Cardiometabolic Risk (If Gdm / Ghtn)
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Transition Of Care
|
Referral
|
|
Referral Made To Primary Care Provider
|
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Pregnancy Complications Documented In Medical Record
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
Written Recommendations For Follow-Up Communicated To Patient And To Pcp
|
Referral
|
|
NA
|
|
|
Follow-Up NA Date Needed
|
|
|
Comments:
|
Date
|
|
|
Referral
|
|
Requests
|
|
|
Tubal Sterilization Consent Signed (If Desired)
|
|
|
Date
|
|
|
History And Physical Have Been Sent To Hospital, If Applicable.
|
|
|
Date
|
Initials
|
|
Update With Group B Streptococcus Results Sent.
|
|
|
Date
|
Initials
|
|
|
|
|
Comments
|
Initials
|
|
Plans/Education Notes
|
|
