35(9,286(',7,21,612786$%/( 161

'$7(
MEDICAL RECORD PRENATAL AND PREGNANCY

PATIENT INFORMATION
/$671$0( ),5671$0( 0,''/(,1,7,$/

675((7$''5(66 &,7< 67$7( =,3&2'(

7(/(3+21(+RPH 7(/(3+21(:RUN ,'180%(5 '$<2)%,57+0RQWK'D\<HDU $*(

$5($&2'( 180%(5 $5($&2'( 180%(5 (;7

5$&( ('8&$7,21/DVWJUDGH 2&&83$7,21

FRPSOHWHG
:+,7( +,63$1,&:+,7( $0(5,&$1,1',$1$/$6.$1$7,9( +20(0$.(5
2876,'(:25.
%/$&. +,63$1,&%/$&. $6,$13$&,),&,6/$1'(5 678'(17
0$57,$/67$786 7<3(2):25.
6,1*/( 0$55,('
:,'2:('
',925&(' 6(3$5$7(' (0(5*(1&<&217$&7 7(/(3+21(
+86%$1')$7+(52)%$%< $5($&2'( 180%(5
1$0( 7(/(3+21(
$5($&2'( 180%(5 1(:%251
63+<6,&,$1 5()(55('%<

),1$/(67,0$7(''(/,9(5<'$7( +263,7$/2)'(/,9(5< 35,0$5<3529,'(5*5283 0(',&$,'180%(5,1685$1&(

NUMBER OF PREGNANCIES
727$/ )8//7(50 35(0$785( $%257,216,1'8&7(' $%257,21663217$1(286 (&723,&6 08/7,3/(%,57+6 /,9,1*

PAST PREGNANCIES (LAST SIX)

35(7(50
'$7( *$ /(1*7+ %,57+ 6(; 7<3( $1(67+(6,$
PLACE OF /$%25 &200(176
2) :(,*+7 '(/,9(5<
02<5 :((.6 /$%25 '(/,9(5< DELIVERY &203/,&$7,216
) 0 <(6 12

MENSTRUAL HISTORY
/$670(16758$/3(5,2' 0(16(6 )5(48(1&< 0(1$5&+(
'(),1,,7( $3352;,0$7(0217+.12:1 0217+/< 35,25'DWH 4'D\V 21%&3$7 $*(216(7 K&*'DWH
81.12:1 1250$/$02817'85$7,21 <(6 &21&(37
),1$/ 12 <(6 12
SYMPTOMS SINCE LAST MENSTRUAL PERIOD
'(6&5,%($//6<037206

5(/$7,216+,3726321625 6321625
61$0( 6321625
6,'180%(5
/$67 ),567 0, 661RU2WKHU

'(3$576(59,&( +263,7$/250(',&$/)$&,/,7< 5(&25'60$,17$,1('$7

3$7,(17
6,'(17,),&$7,21)RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,'1R 5(*,67(512 :$5'12
RU6616H[

PRENATAL AND PREGNANCY

Medical Record

67$1'$5')2505(9
3UHVFULEHGE\*6$,&05)305&)5
 161
/$671$0( ),5671$0( 0,''/(,1,7,$/ ,'180%(5

PAST MEDICAL HISTORY

O NEG DETAIL POSITIVE REMARKS O NEG DETAIL POSITIVE REMARKS
,7(0 (Include Date and Treatment) ,7(0 (Include Date and Treatment)
+ POS + POS
PULMONARY
DIABETES (TB, ASTHMA)

HYPERTENSION ALLERGIES (DRUGS)

HEART DISEASE BREAST

AUTOIMMUNE HISTORY OF
DISORDER ABNORMAL PAP
UTERINE ANOMALY/
KIDNEY DISEASE/UTI DES

PSYCHIATRIC INFERTILITY

NEUROLOGIC/ RELEVANT FAMILY

EPILEPSY HISTORY
HEPATITIS/LIVER
DISEASE
GYN SURGERY
VARICOSITIES/
PHLEBITIS
THYROID
DYSFUNCTION OPERATIONS/HOS-
PITALIZATIONS
TRAUMA/DOMESTIC (Year and Reason)
VIOLENCE
HISTORY OF BLOOD ANESTHETIC
TRANSFUSION COMPLICATIONS
OTHER (Specify)
D (RH) SENSITIZED

USE OF TOBACCO USE OF ALCOHOL USE OF STREET DRUGS

180%(52)&,*(5$77(6 122) 180%(52)'5,1.63(5'$< 122)<($56 $028173(5'$< 122)<($5686(
3(5'$< <($56 35,2572 12: '5,1.,1* 35,2572 12:
602.(' 35(*1$1&< 35(*1$1&<
35,257235(*1$1&< 12:

&200(176&2816(/,1*

GENETICS SCREENING/TERATOLOGY COUNSELING

(Includes Patient, Baby's Father, or anyone in Either Family)

,7(0 <(6 12 ,7(0 <(6 12

3$7,(17
6$*(,6*5($7(57+$1<($56
0(17$/5(7$5'$7,21$87,60
7+$/$66(0,$,7$/,$1*5((.0(',7(55$1($125$6,$1
%$&.*5281'0&9,6/(667+$1
,)<(6:$63(56217(67(')25)5$*,/(;
1(85$/78%('()(&70(1,1*20<(/2&(/(63,1$%,),'$25
$1(1&(3+$/< 27+(5,1+(5,7('*(1(7,&25&+5202620$/',625'(5
&21*(1,7$/+($57'()(&7 0$7(51$/0(7$%2/,&',625'(5 (*,168/,1'(3(1'(17
'2:16<1'520( ',$%(7(63.8
7$<6$&+6(*-(:,6+&$-81)5(1&+&$1$',$1 3$7,(1725%$%<
6)$7+(5+$'$&+,/':,7+%,57+'()(&76
6,&./(&(//',6($6(2575$,7$)5,&$1 127/,67('$%29(
+(023+,/,$ 0(',&$7,216675((7'58*6$/&2+2/6,1&(/$670(16758$/
086&8/$5'<67523+< 3(5,2'
&<67,&),%526,6 ,)<(6/,67$*(176
+817,1*721&+25($
5(&855(175(*1$1&</26625$67,//%,57+ $1<27+(5
&200(176&2816(/,1*

67$1'$5')2505(93$*(

 161
INFECTION HISTORY
,7(0 <(6 12 ,7(0 <(6 12
+,*+5,6.+(3$7,7,6%,0081,=(' 5$6+259,5$/,//1(666,1&(/$670(16758$/3(5,2'
/,9(:,7+620(21(:,7+7% +,6725<2)67'*&&+/$0<',$+396<3+,/,6
(;326('727% 27+(5
3$7,(17253$571(5+$6+,6725<2)*(1,7$/+(53(6
&200(176

'58*$//(5*< 5(/,*,286&8/785$/&216,'(5$7,216 $1(67+(6,$&2168/73/$11('

<(6 12

INTERVIEWER'S SIGNATURE

INITIAL PHYSICAL EXAMINATION

(;$0'$7( 35(35(*1$1&<:(,*+7 35(6(17:(,*+7 +(,*+7 %3

&+(&.21(
,7(0 ,7(0 5(68/7
1250$/ $%1250$/
+((17 98/9$ 1250$/ &21'</20$ /(6,216
)81', 9$*,1$ 1250$/ ,1)/$00$7,21 ',6&+$5*(
7((7+ &(59,; 1250$/ ,1)/$00$7,21 /(6,216
7+<52,' 122):((.6
87(5866,=( ),%52,'6
%5($676
/81*6 $'1(;$ 1250$/ 0$66
+($57 &0
',$*21$/
5($&+(' 12
$%'20(1 &21-8*$7(

(;75(0,7,(6 63,1(6 $9(5$*( 3520,1(17 %/817

6.,1 6$&580 &21&$9( 675$,*+7 $17(5,25
/<03+12'(6 68%38%,&$5&+ 1250$/ :,'( 1$552:
5(&780 *<1(&2,'3(/9,&7<3( <(6 12
&200(176/LVWW\SHDQGH[SODLQDEQRUPDOLW\

0(',&$7,21/,67
352%/(06 3/$16
7<3( 67$57'$7( 6723'$7(

ESTIMATED DELIVERY DATE (EDD)

&21),50$7,21
$&7,21 '$7( :((.6 ('' ,1,7,$/(''
/03
,1,7,$/(;$0 ,1,7,$/('%<
8/75$6281'
18-20 WEEK UPDATE
$&7,21 25*'$7( :((.6 1(:'$7( ),1$/(''
48,&.(1,1*
)81'$/+7$780%,/
,1,7,$/('%<
)+7:)(726&23(
8/75$6281'
3$7,(17
6,'(17,),&$7,21)RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,' 5(*,67(512 :$5'12
1RRU6616H['DWHRI%LUWK5DQN*UDGH

67$1'$5')2505(93$*(

 161
/$671$0( ),5671$0( 0,''/(,1,7,$/ ,'180%(5

9,6,76

&(59,;(;$0
35(7(50/$%25
:((.6*(67

+(,*+7&0

0(17'DWH
6,*166<037206

029(0(17
%(67(67

35(6(17$
%/22' 85,1(

3529,'(5
',/())

$332,17
35(6 */8&26( &200(176
)81'$/
'$7(

:(,*+7

,QLWLDOV
('(0$
685( $/%80,1

)(7$/
$%6

1(;7
67$
35(6(17
7,21 (17
)+5

352%/(06 &200(176

67$1'$5')2505(93$*(

 161

LABORATORY AND EDUCATION

7<3( '$7( 5(68/7 5(9,(:(' COMMENTS/ADDITIONAL LAB

$ %
%/22'7<3(
$% 2

'5+7<3(

1250$/ 27+(5
3$37(67
$%1250$/
326,7,9(
+,9&2816(/,1*7(67,1* '(&/,1('
1(*$7,9(
INITIAL LABS

$17,%2'<6&5((1

58%(//$

9'5/

3(5&(17$*( *'/
+&7+*%

85,1(&8/785(6&5((1

+%V$*

$$ $6 66 $&
+*%(/(7523+25(6,6
6& $) 7$

33'
OPTIONAL LABS

&+/$0<',$

*&

7$<6$&+6

27+(5

8/75$6281'
(When indicated/elected)
8-18 WEEK LABS

06$)308/7,3/(0$5.(56

$01,2&96

;; 27+(5
.$5<27<3(
;<

$01,27,&)/8,'$)3 1250$/ $%1250$/

3$7,(17
6,'(17,),&$7,21)RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,' 5(*,67(512 :$5'12
1RRU6616H[5DQN*UDGH

67$1'$5')2505(93$*(

 161
/$671$0( ),5671$0( 0,''/(,1,7,$/ ,'180%(5

7<3( '$7( 5(68/7 5(9,(:(' COMMENTS/ADDITIONAL LAB

3(5&(17$*( *'/
+&7+*%
24-28 WEEK LABS

+285
',$%(7(66&5((1

)%6 +285
*77,IVFUHHQDEQRUPDO
+285 +285

'5+$17,%2'<6&5((1

',0081(*/2%8/,15+* 6,*1$785(

*,9(1:((.6
3(5&(17$*( *'/
+&7+*%5HFRPPHQGHG

8/75$6281'
32-36 WEEK LABS

9'5/

*&

&+/$0<',$

*5283%675(3
:((.6

PLANS/EDUCATION
7<3( &200(176 7<3( &200(176

&2816(/(' 1(:%251&$56($7

$1(67+(6,$3/$16 32673$5780%,57+&21752/

72;23/$6026,6 (19,5210(17$/:25.
35(&$87,216&$765$: +$=$5'6
0($7

&+,/'%,57+&/$66(6 78%$/67(5,/,=$7,21

3+<6,&$/6(;8$/$&7,9,7< 9%$&&2816(/,1*

/$%256,*16 &,5&80&,6,21

1875,7,21&2816(/,1* 75$9(/

/,)(67</(72%$&&2
%5($6725%277/()((',1* $/&2+2/

5(48(676 TUBAL STERILIZATION

'$7(&216(176,*1(' ,1,7,$/6

&200(176&2816(/,1*

67$1'$5')2505(93$*(

 161
SUPPLEMENTAL VISITS

&(59,;(;$0
35(7(50/$%25
:((.6*(67

+(,*+7&0

0(17'DWH
6,*166<037206

029(0(17
%(67(67

35(6(17$
%/22' 85,1(

3529,'(5
',/())

$332,17
35(6 */8&26( &200(176
)81'$/
'$7(

:(,*+7

,QLWLDOV
('(0$
685( $/%80,1

)(7$/
$%6

1(;7
67$
35(6(17

7,21
(17

)+5

352*5(66127(6

3$7,(17
6,'(17,),&$7,21)RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,' 5(*,67(512 :$5'12
1RRU6616H[5DQN*UDGH

67$1'$5')2505(93$*(

 161
/$671$0( ),5671$0( 0,''/(,1,7,$/ ,'180%(5

352*5(66127(6

67$1'$5')2505(93$*(

 161

DISCHARGE/POSTPARTUM

DELIVERY INFORMATION
'(/,9(5<'$7( TYPE OF DELIVERY

9$*,1$/ &(6$5($1
'(/,9(5<$7:HHNV 69' (3,6,2720< )25 5(3($7)$,/('9%$&
35,0$5<
9$&880 /$&(5$7,216 /2:75$169(56(
)25&(36 9%$& &/$66,&$/ 5(3($7(/(&7,9( /2:9(57,&$/
/$%25 $1(67+(6,$
63217$1(286 $8*0(17(' 121( (3,'85$/ *(1(5$/
,1'8&(' 12/$%25 /2&$/38'(1'$/ 63,1$/ 27+(5
POSTPARTUM COMPLICATIONS
121( +(0255+$*( ,1)(&7,21 +<3(57(16,21 27+(5
',6&+$5*('$7(
DISCHARGE INFORMATION

1(21$7$/
6(; ',6326,7,21 &203/,&$7,216$120$/,(6
)(0$/( &,5&80&,6,21 +20(:,7+027+(5 1(21$7$/'($7+
0$/( <(6 12 75$16)(5 27+(5
%,57+:(,*+7 1$0(2)%$%< 67,//%,57+
,1+263,7$/
0$7(51$/
+%+&7/(9(/ &2175$&(37,9(0(7+2',IDSSOLFDEOH 0(',&$7,216

)((',1*0(7+2' ',$*1267,&678',(63(1',1*
%5($67 %277/(
6(&21'$5<',$*126,635((;,67,1*&21',7,216 )2//2:83$332,170(17
$67+0$ 27+(5 '$7( /2&$7,21
',$%(7(6
+<3(57(16,21
,0081,=$7,216*,9(1 5(0$5.6
'5KR',0081(*/2%8/,1
',$%(7(6
27+(5
INTERIM CONTACTS
'$7( &200(17

6,*1$785(2)3529,'(5$65(48,5('

3$7,(17
6,'(17,),&$7,21)RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,' 5(*,67(512 :$5'12
1RRU6616H[5DQN*UDGH

67$1'$5')2505(93$*(

 161
/$671$0( ),5671$0( 0,''/(,1,7,$/ ,'180%(5

POSTPARTUM VISITS
'$7( $//(5*,(6

/$%678',(65(48(67(' 0(',&$7,216&2175$&(37,21

+*%+&7 /$673$360($5'DWH 0(',&$7,216&2175$&(37,21',63(16('

<(6 12
,17(5,0+,6725< )((',1*0(7+2'

&2175$&(37,9(0(7+2'

INTERVAL CARE RECOMMENDATIONS

)25*(1(5$/+($/7+352027,21

)255(352'8&7,9(+($/7+352027,21

5()(55$/6

5(78519,6,7'DWH (;$0,1('%<

PHYSICAL EXAM
%3 :(,*+7 3$360($5

<(6 12
,7(0 1250$/ $%1250$/ &200(176

BREASTS

ABDOMEN

EXTERNAL GENITALS

VAGINA

CERVIX

UTERUS

ADNEXA

RECTAL-VAGINAL
&200(176

67$1'$5')2505(93$*(

 161
&200(176&RQWLQXHRQEDFNLIQHHGHG

3$7,(17
6,'(17,),&$7,21 )RUW\SHGRUZULWWHQHQWULHVJLYH1DPHODVWILUVWPLGGOH,'QR661RU 5(*,67(512 :$5'12
RWKHUKRVSLWDORUPHGLFDOIDFLOLW\

67$1'$5')2505(93$*(