DATE NAME LAST FIRST MIDDLE ID# HOSPITALOFDELIVERY NEWBORN’SPHYSICIAN REFERREDBY FINALEDD PRIMARYPROVIDER/GROUP BIRTHDATE AGE RACE MARITALSTATUS S OCCUPATION ADDRESS SEP (LASTGRADECOMPLETED) HOMEMAKER OUTSIDEWORK STUDENT TypeofWork HUSBAND/FATHEROFBABY TOTALPREG M W D EDUCATION PHONE FULLTERM PREMATURE PHONE EMERGENCYCONTACT AB.INDUCED AB.SPONTANEOUS (O) (H) ZIP PHONE INSURANCECARRIER/MEDICAID# ECTOPICS MULTIPLEBIRTHS LIVING MENSTRUALHISTORY LMP DEFINITE UNKNOWN APPROXIMATE(MONTHKNOWN) MENESMONTHLY NORMALAMOUNT/DURATION PRIORMENES YES NO FREQUENCY:Q DATE ONBCPATCONCEPT. DAYS YES MENARCHE NO hCG+ (AGEONSET) / / FINAL PASTPREGNANCIES(LASTSIX) DATE GA MONTH/ WEEKS YEAR LENTGH BIRTH OF WEIGHT LABOR SEX M/F TYPE DELIVERY ANES PRETERM LABOR YES/NO PLACEOF DELIVERY COMMENTS/COMPLICATIONS PASTMEDICALHISTORY ONeg +Pos DETAILPOSITIVEREMARKS INCLUDEDATE&TREATMENT ONeg +Pos 1.DIABETES 16.D(Rh)SENSITIZED 2.HYPERTENSION 17.PULMONARY(TB,ASTHMA) 3.HEARTDISEASE 18.ALLERGIES(DRUGS) 4.AUTOIMMUNEDISORDER 19.BREAST 5.KIDNEYDISEASE/UTI 20.GYNSURGERY 6.NEUROLOGIC/EPILEPSY 7.PSYCHIATRIC 8.HEPATITIS/LIVERDISEASE 21.OPERATION/HOSPITALIZATIONS (YEAR&REASON) 9.VARICOSITIES/PHLEBITIS 10.THYROIDDYSFUNCTION 22.ANESTHETICCOMPLICATIONS 11.TRAUMA/DOMESTICVIOLENCE 23.HISTORYOFABNORMALPAP 12.HISTORYOFBLOODTRANSFUS AMT/DAY PREPREG AMT/DAY PREPREG #YEARS USE 24.UTERINEANOMALY/DES 13.TOBACCO 25.INFERTILITY 14.ALCOHOL 26.RELEVANTFAMILYHISTORY 15.STREETDRUGS 27.OTHER COMMENTS: TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920 DETAILPOSITIVEREMARKS INCLUDEDATE&TREATMENT SYMPTOMSSINCELMP YES NO YES NO 12.MENTALRETARDATION/AUTISM 1.PATIENT’SAGE(35OROLDER) 2.THALASSEMIA(ITALIAN,GREEK,MEDITERRANEAN,ORASIAN BACKGROUND)MCV<80 IFYES,WASPERSONTREATEDFORFRAGILEX? 13.OTHERINHERITEDGENETICORCHROMOSOMALDISORDER 3.NEURALTUBEDEFECT (MENINGOMYELOCELE,SPINABIFIDA,ORANENCEPHALY) 14.MATERNALMETABOLICDISORDER(EG.INSULINDEPENDENT DIABETES,PKU) 4.CONGENITALHEARTDEFECT 5.DOWNSYNDROME 15.PATIENTORBABY’SFATHERHADACHILDWITHBIRTHDEFECTS NOTLISTEDABOVE 6.TAY-SACHS(EG.JEWISH,CAJUN,FRENCH-CANADIAN 16.RECURRENTPREGNANCYLOSS,ORASTILLBIRTH 7.SICKLECELLDISEASEORTRAIT(AFRICAN) 17.MEDICATIONS/STREETDRUGS/ALCOHOLSINCELASTMENSTRUAL PERIOD 8.HEMOPHILIA IFYES,AGENT(S) 9.MUSCULARDYSTROPHY 10.CYSTICFIBROSIS 18.ANYOTHER 11.HUNTINGTONCHOREA COMMENTS/COUNSELING INFECTIONHISTORY YES NO YES 1.HIGHRISKHEPATITISB/IMMUNIZED? 4.RASHORVIRALILLNESSSINCELASTMENSTRUALPERIOD 2.LIVEWITHSOMEONEWITHTBOREXPOSEDTOTB 5.HISTORYOFSTD.GC.CHLAMYDIAHPV.SYPHILIS 3.PATIENTORPARTNERHASHISTORYOFGENITALHERPES 6.OTHER(SEECOMMENTS NO COMMENTS INTERVIEWER’SSIGNATURE INITIALPHYSICALEXAMINATION DATE / / PREPREGNANCYWEIGHT HEIGHT BP 1.HEENT NORMAL ABNORMAL 12.VULVA NORMAL ABNORMAL 2.FUNDI NORMAL ABNORMAL 13.VAGINA NORMAL ABNORMAL 3.TEETH NORMAL ABNORMAL 14.CERVIX NORMAL ABNORMAL 4.THYROID NORMAL ABNORMAL 15.UTERUSSIZE NORMAL ABNORMAL 5.BREASTS NORMAL ABNORMAL 16.ADNEXA NORMAL ABNORMAL 6.LUNGS NORMAL ABNORMAL 17.RECTUM NORMAL ABNORMAL 7.HEART NORMAL ABNORMAL 18.DIAGONALCONJUGATE NORMAL ABNORMAL 8.ABDOMEN NORMAL ABNORMAL 19.SPINES NORMAL ABNORMAL 9.EXTREMITIES NORMAL ABNORMAL 20.SACRUM NORMAL ABNORMAL 10.SKIN NORMAL ABNORMAL 21.SUBPUBICARCH NORMAL ABNORMAL ABNORMAL 22.GYNECODPELVICTYPE NORMAL ABNORMAL 11.LYMPHNODE NORMAL COMMENTS (Numberandexplainabnormals) EXAMBY TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920 NAME LAST FIRST MIDDLE DRUGALLERGY RELIGIOUS/CULTURALCONSIDERATIONS ANESTHESIACONSULTPLANNED PROBLEMS/PLANS MEDICATIONLIST: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. YES StartDate NO StopDate 6. EDDCONFIRMATION INITIALEDD: LMP / / INITIALEXAM / / = ULTRASOUND / / = INITIALEDD / / 18-20-WEEKEDDUPDATE: / / +22WKS = / / = EDD / / FUNDALHT.ATUMBIL / / +20WKS = / / WKS = EDD / / FHTW/FETOSCOPE / / +20WKS = / / WKS = EDD / / ULTRASOUND / / = WKS = / / FINALEDD / / INITIALEDBY QUICKENING INITIALEDBY VISITDATE (YEAR) COMMENTS: PROBLEMS: COMMENTS: TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920 LABORATORYANDEDUCATION INITIALLABS DATE RESULT BLOODTYPE / / D(Rh)TYPE / / ANTIBODYSCREEN / / HCT/HGB / / PAPTEST / / RUBELLA / / VDRL / / URINECULTURE/SCREEN / / HBsAg / / HIVCOUNSELING/TESTING / / OPTIONALLABS B / / / / / / GC / / TAY-SACHS / / OTHER / % POS AA NEG AS DECLINED SS AC REVIEWED SC Ta2 AF / RESULT ULTRASOUND / / MSAFP/MULTIPLEMARKERS / / AMNIO/CVS / / KARYOTYPE / / 46.XX AMINOTICFLUID(AFP) / / NORMAL OR 46.XY REVIEWED / OTHER ABNORMAL DATE 2 4 - 2 8 - W E E K L A B S (WHENINDICATED) g/dl COMMENTS/ADDITIONALLABS DATE (WHENINDICATED) O RESULT PPD CHLAMYDIA AB NORMAL/ABNORMAL/ DATE HGBELECTROPHORESIS 8-18-WEEKLABS A REVIEWED RESULT REVIEWED HCT/HGB / / % DIABETESSCREEN / / 1HOUR GTT(IFSCREENABNORMAL) / / FBS 1HOUR 2HOUR 3HOUR D(Rh)ANTIBODYSCREEN / / DIMMUNEGLOBULIN(RhIG)GIVEN(28WKS) / / 3 2 - 3 6 - W E E K L A B S (WHENINDICATED) DATE SIGNATURE RESULT HCT/HGB(RECOMMENDED) / / ULTRASOUND / / VDRL / / GC / / CHLAMYDIA / / GROUPBSTREP(35-37WKS) / / PLANS/EDUCATION (COUNSELED g/dl REVIEWED % g/dl ) ANESTHESIAPLANS TUBALSTERILIZATION TOXOPLASMOSISPRECAUTIONS(CATS/RAWMEAT) VSACCOUNSELING CHILDBIRTHCLASSESS CIRCUMCISION PHYSICAL/SEXUALACTIVITY TRAVEL LABORSIGNS NUTRITIONCOUNSELING LIFESTYLE,TOBACCO,ALCOHOL REQUESTS BREASTORBOTTLEFEEDING NEWBORNCARSEAT POSTPARTUMBIRTHCONTROL ENVIRONMENTAL/WORKHAZARDS TUBALSTERILIZATION CONSENTSIGNED PROVIDERSIGNATURE(ASREQUIRED) TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920 DATE / INITIALS / NAME LAST FIRST MIDDLE ID# SupplementalVisits VISITDATE (YEAR) COMMENTS: Progress Notes PROVIDERSIGNATURE(REQUIRED) TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920 NAME LAST MIDDLE FIRST ID# ProgressNotes PROVIDERSIGNATURE(REQUIRED) TheAmericanCollegeofObstetriciansansGynecologists40912thStreetSWPOBox96920WashingtonDC20090-6920
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