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PATIENT CONSENT - TELEMEDICINE ONLY
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Patient Consent
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Patient consent given for telemedicine by:
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Vitals Obtained
• • •
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Start Time
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End Time
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EDD (Est. Due Date)
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Hospital of Delivery:
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Primary Care Physician of Mother
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OBGYN Name:
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Have you chosen your baby's doctor?
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Newborn's Physician/Pediatrician Name:
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PAST PREGNANCY HISTORY
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Total Pregnancies (including this pregnancy):
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Have you had Multiple Births? List:
• • •
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How many are living out of all pregnancies?
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Did you Terminate any Pregnancies? How many?
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Have you had any Miscarriages? How many?
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Ectopic Pregnancy?
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How many were PRETERM?
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How many were FULL TERM?
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On BCP at Conception?
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Past Pregnancies - detail
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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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1 - Birth Wt Lbs
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1 - 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 of Delivery
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2 - Sex
• • •
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2 - Birth Wt Lbs
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2 - Birth Wt 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 Wt Lbs
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3 - Birth Wt 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 Wt Lbs
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4 - Birth Wt 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 Wt Lbs
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5 - Birth Wt Oz
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5 - Comments
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MEDICAL 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. Hepatitis/Liver Disease
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Comments
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7. Thyroid Dysfunction
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Comments
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8. Neurologic/Seizure Disorder:
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Comments
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9. Psych/Depression/Postpartum Depression:
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Comments
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10. Varicosities/Phlebitis:
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Comments
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11. History of Blood Transfusion:
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Comments
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12. D (Rh) Sensitized:
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Comments
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13. Pulmonary (TB, Asthma):
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Comments
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14. Breast Issues:
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Comments
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15. Trauma/Violence/Sexual Abuse:
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Comments
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16. Genetic History/Teratology:
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Comments
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17. Anesthetic Complications:
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Comments
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18. History of Abnormal Pap:
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Comments
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19. Uterine Anomaly:
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Comments
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20. Infertility / Treatment:
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Comments
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21. Relevant Family History:
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Comments
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Medical History Comments
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SURGICAL HISTORY / HOSPITALIZATIONS
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Gynecological Surgeries:
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Type and Year of Surgery
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Surgeries/Hospitalizations: (Non-OB)
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Type and Year of Surgery/Hospitalization
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MEDICATION REVIEW & OVER THE COUNTER DRUGS
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Medications / OTC (use dictation, e.g. "lisinopril for HTN")
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Drug/Latex Allergies
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Comments
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IMMUNIZATION STATUS
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Are you up to date on all of your immunizations, Tdap, measles–mumps–rubella, hepatitis B, and varicella?
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EXPOSURE / PAST DISEASE
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1. TB?
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2. Pt/Partner history 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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TOBACCO, ALCOHOL, SUBSTANCE USE
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Tobacco Use
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Tobacco Use?
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Tobacco: # YEARS USE
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AMT/DAY DURING PREGNANCY
• • •
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AMT/DAY PRE-PREGNANCY
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Turn ON if answered yes to Tobacco:
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Alcohol Use
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Alcohol Use?
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Alcohol: # YEARS USE
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Alcohol: AMT/DAY PREG
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Alcohol: AMT/DAY PREPREG
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Turn ON if answered yes to Alcohol Use:
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Substance Use
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Illicit/Recreational Drug Use?
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Drugs: # YEARS USE
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Drugs: AMT/DAY DURING PREGNANCY
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DRUGS USED
• • •
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Comments
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Turn ON if answered yes to Substance Use:
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MENSTRUATION HISTORY
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Last Menstrual Period (LMP)?
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Certainty on LMP?
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Normal Amount/Duration
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Menses Monthly?
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Menarche (age at first menarche)
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Frequency?
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Symptoms Since LMP?
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Menstrual Hx Comments
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GESTATIONAL AGE & EDD
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PrePregnancy Weight
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Current Weight:
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When did you have your Initial Exam (MM/DD/YYYY)?
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When was your first ultrasound (MM/DD/YYYY)?
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Second Ultrasound Date (if applicable):
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GA: How far along are you (wks/days)?
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GA Certainty
• • •
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Weeks of Gestation (drops Dx):
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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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EDD Comments
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COUNSELING / EDUCATION
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Turn ON if Counseled
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ASSESSMENT & PLAN
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Prenatal Status (Drops Dx Code and CPT2):
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1. Assessment & Plan
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2. Assessment & Plan
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3. Assessment & Plan
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4. Assessment & Plan
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5. Assessment & Plan
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REFERRALS / NOTES TO PCP/OBGYN
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TURN ON for Referrals & NOTES TO PCP/OBGYN
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Notes to PCP/OBGYN:
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