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EDD FINAL (MD ONLY)
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Total Pregnancies:
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FULL TERM
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PRETERM
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TOP
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Miscarriages
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Ectopic Pregnancy?
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Multiple Births
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Living
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LMP
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Certain on LMP
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Normal Amount/Duration
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Menses Monthly?
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Menarche
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Frequency
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Menstrual Hx Comments
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On BCP at Conception?
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1 Past Pregnancy Year
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1 GA Weeks
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1 Type of Delivery
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1 Sex
• • •
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Birth Wt Lbs
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Birth Wt Oz
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1 Comments
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2 Past Pregnancy Year
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2 GA Weeks
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2 Type Delivery
• • •
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2 Sex
• • •
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2 Birth Weight (lbs)
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2 Birth Weight (oz)
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2 Comments
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3 Past Pregnancy Year
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3 GA Weeks
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3 Type of Delivery
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3 Sex
• • •
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3 Birth Weight (Lbs)
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3 Birth Weight (oz)
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3 Comments
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4 Past Pregnancy Year
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4 GA Weeks
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4 Type of delivery
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4 Sex
• • •
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4 Birth Weight (lbs)
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4 Birth Weight (oz)
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4 Comments
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5 Past Pregnancy Year
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5 GA Weeks
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5 Type of Delivery
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5 Sex
• • •
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5 Birth Weight (lbs)
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5 Birth Weight (oz)
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Comments
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Medical History
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ALL NORMAL ----- OR------>
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Turn On For Detailed History
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1. Diabetes: (Non-Pregnant)
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Comments
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2. Hypertension (Non-Pregnant)
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Comments
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3. Heart Disease
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Comments
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4. Autoimmune Disorder
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Comments
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5. Kidney Disease/UTI
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Comments
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6. Neurologic/Epilepsy:
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Comments
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7. Psychiatric
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Comments
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8. Depression/Postpartum Depress
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Comments
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9. Hepatitis/Liver Disease
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Comments
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10. Variscosities/Phlebitis
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Comments
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11. Thyroid Dysfunction
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Comments
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12. Trauma/Violence/Sexual Abuse
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Comments
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13. History of Blood Transfusion
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Comments
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14. Tobacco
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Tobacco: AMT/DAY PREPREG
• • •
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Tobacco: AMT/DAY PREG
• • •
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Tobacco: # YEARS USE
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15. Alcohol
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Alcohol: AMT/DAY PREPREG
• • •
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Alcohol: AMT/DAY PREG
• • •
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Alcohol: # YEARS USE
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16. Illicit/Recreational Drugs
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DRUGS USED
• • •
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Drugs: AMT/DAY PREG
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Drugs: # YEARS USE
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17. D (Rh) Sensitized
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Comments
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18. Pulmonary (TB, Asthma)
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Comments
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19. Seasonal Allergies
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Comments
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20. Drug/Latex Allergies
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Comments
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21. Breast
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Comments
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22. Gyn Surgery
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Comments
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23. Operations/Hospitalizations: (Non-OB)
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Year and Reason
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24. Anesthetic Complications
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Comments
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25. History of Abnormal Pap
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Comments
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26. Uterine Anomaly/DES
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Comments
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27. Infertility
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Comments
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28. ART Treatment
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Comments
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29. Relevant Family History
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Comments
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30: Other
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Medical History Comments
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Symptoms Since LMP
• • •
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Comments
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Genetic History/Teratology
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Genetics All Negative--- OR --->
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Detailed Genetic Screening:
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1. Patients Age 35>= By EDD
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2. Thalassemia Ita,Grk,Med,Asi
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3. Neural Tube Defect
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4. Congenital heart defect
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5. Down Syndrome
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6. Tay-Sachs (AshJew, Caj, Fre)
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7. Canavan Disease (Ash Jew)
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8. Familial Dsyautonomia (Jew)
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9. Sickle Cell disease (African)
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10. Hemophilia or blood dis
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11. Muscular Dystrophy
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12. Cystic Fibrosis
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13. Huntington's Chorea
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14. Mental/Retardation/Autism
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14b. If yes, Fragile X?
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15. Other gen/chrom disorder
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16. Maternal Metabolic Disorder
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17. Other Birth Defects
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18. Recurrent Loss or Stillbirth
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19. Medications
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20. Any Other
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Genetics Father/Comments
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1. Live with TB or exposed?
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2. Pt,FOB hx of Genital Herpes?
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3. Rash, Virus since LMP?
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4. Hepatitis B, C
• • •
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5. History of STD
• • •
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Infection History Comments (recent travel/Zika)
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PrePregnancy Weight
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1. HEENT NORMAL
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FINDINGS
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2. FUNDI NORMAL
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FINDINGS
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3. TEETH NORMAL
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FINDINGS
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4. THYROID NORMAL
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FINDINGS
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5. BREASTS NORMAL
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FINDINGS
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6. LUNGS NORMAL
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FINDINGS
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7. HEART NORMAL
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FINDINGS
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8. ABDOMEN NORMAL
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FINDINGS
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9. EXTREMITIES NORMAL
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FINDINGS
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10. SKIN NORMAL
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FINDINGS
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11. LYMPH NODES NORMAL
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FINDINGS
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12. VULVA NORMAL
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FINDINGS
• • •
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13. VAGINA NORMAL
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FINDINGS
• • •
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14. CERVIX NORMAL
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FINDINGS
• • •
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UTERUS SIZE (WEEKS)
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FIBROIDS
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16. ADNEXA NORMAL
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FINDINGS
• • •
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17. RECTUM NORMAL
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FINDINGS
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18. Normal Pelvimetry (Yes)
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Pelvimetry N/A
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Initial PE Comments
|
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LMP
|
= EDD
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Initial Exam
|
GA WksDays
|
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= EDD
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Early Ultrasound
|
GA WksDays
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= EDD
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Ultrasound (18-20 WK update)
|
GA WksDays
|
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EDD by Ultrasound
|
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IT'S A BOY
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IT'S A GIRL
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Gender Surprise
|
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Final EDD
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Initialed By: ER
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EDD Comments
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