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LABS
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Healthy Start Form
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INITIAL LABS:
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INITIAL LABS Date:
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Hgb / Hct:
/
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BLOOD Type (ABO/Rh):
• • •
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Antibody Screen:
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Antibody Comment
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Hgb ELECTROPHORESIS:
• • •
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Rubella:
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HIV Positive?
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RPR Reactive?
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HbsAg Positive?
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Urine Culture
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PAP
• • •
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Gonorrhea Positive?
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Chlamydia Positive?
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Cystic Fibrosis Result:
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Other Genetic Screening Test(s):
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TSH:
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Initial Lab Other/Comments
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1st Trimester Screen
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1st trimester screen date
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1st Trimester Screen Result: (NT/CVS)
• • •
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NIPT
• • •
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2nd Trimester Screen
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2nd trimester screen date
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2nd Trimester Screen Result:
• • •
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2nd TM Screen Comment
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24-28 WEEK LABS
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24-28 WEEK LAB DATE
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HIV Positive?
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50g 1° GTT
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HbsAg Positive?
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RPR Reactive?
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Hemoglobin
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Hematocrit
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GTT (date: fasting/1/2/3 hr)
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Third Trimester Lab Other/Comments
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Rhogam
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RHOGAM DATE/ Lot & Exp
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36 Week Cultures
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Culture Date
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GBS Positive?
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Chlamydia Positive?
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Gonorrhea Positive?
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RECORDS PROVIDED TO PATIENT
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Date Provided
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Pediatrician
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Pediatrician Comments
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Circumcision
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PRIVATE CORD BLOOD BANKING
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OB Visit #2
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OB Visit #3
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OB Visit #4
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OB Visit #5
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OB Visit #6
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OB Visit #7
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OB Visit #8
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OB Visit #9
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OB Visit #10
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OB Visit #11
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OB Visit #12
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OB VISIT #13
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OB VISIT #14
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OB VISIT #15
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Antepartum Flow Sheet
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1. Prenatal Visit 1
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Comments
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Plan/Orders:
• • •
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Discussed
• • •
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Visit #2
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2. Prenatal Visit 2
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Plan/Orders:
• • •
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Discussed
• • •
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Visit #3
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3. Prenatal Visit 3
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Plan/Orders:
• • •
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Discussed
• • •
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Visit #4
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4. Prenatal Visit 4
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Discussed
• • •
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Visit #5
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5. Prenatal Visit 5
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Discussed
• • •
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Visit #6
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6. Prenatal Visit 6
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Discussed
• • •
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Visit #7
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7. Prenatal Visit Date
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Discussed
• • •
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Visit #8
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8. Prenatal Visit 8
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Discussed
• • •
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Visit #9
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9. Prenatal Visit 9
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Discussed
• • •
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Visit #10
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10. Prenatal Visit 10
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Discussed
• • •
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Visit #11
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11. Prenatal Visit 11
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Discussed
• • •
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Visit #12
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12. Prenatal Visit 12
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Discussed
• • •
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Visit #13
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13. Prenatal Visit 13
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Discussed
• • •
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Visit #14
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14. Prenatal Visit 14
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Discussed
• • •
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Visit #15
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13. Prenatal Visit 15
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Discussed
• • •
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NICA
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