medical record prenatal and pregnancy

Q (Days) hCG + (Date)

NSN 7540-00-634-4276PREVIOUS EDITION IS NOT USABLE

MEDICAL RECORD PRENATAL AND PREGNANCYDATE

PATIENT INFORMATIONLAST NAME

ID NUMBER

STREET ADDRESS

FIRST NAME MIDDLE INITIAL

CITY STATE ZIP CODE

DAY OF BIRTH (Month, Day, Year) AGE

APPROXIMATE (MONTH KNOWN)

NORMAL AMOUNT/DURATION

FINAL:

MENSESPRIOR (Date)

FREQUENCYAGE ONSETMONTHLY

YES

NO

ON BCP AT CONCEPT

YES NO

MENARCHE

OUTSIDE WORK

FULL TERM PREMATURE ABORTIONS INDUCTED ABORTIONS SPONTANEOUS ECTOPICS MULTIPLE BIRTHS LIVINGTOTAL

PAST PREGNANCIES (LAST SIX)

DATE (MO/YR)

GA WEEKS

LENGTH OF

LABOR

BIRTH WEIGHT

SEX TYPE DELIVERY ANESTHESIA PLACE OF

DELIVERY

PRETERM LABOR

DELIVERYYES NOF M

MENSTRUAL HISTORYLAST MENSTRUAL PERIOD

DEFINITE

UNKNOWN

TELEPHONEAREA CODE NUMBER

FINAL ESTIMATED DELIVERY DATE

WHITE

BLACK

HISPANIC WHITE

HISPANIC BLACK

AMERICAN INDIAN/ALASKA NATIVE

ASIAN/PACIFIC ISLANDER

DESCRIBE ALL SYMPTOMSSYMPTOMS SINCE LAST MENSTRUAL PERIOD

MARITAL STATUS

WIDOWEDSINGLE

DIVORCED

MARRIED

SEPARATED

OCCUPATION

TYPE OF WORK

EDUCATION (Last grade completed)

HOMEMAKER

STUDENT

COMMENTS/ COMPLICATIONS

RACE

EMERGENCY CONTACT

REFERRED BY

MEDICAID NUMBER/INSURANCE

TELEPHONE (Home)AREA CODE NUMBER

TELEPHONEAREA CODE NUMBER

NEWBORN'S PHYSICIAN

HOSPITAL OF DELIVERY

NUMBER OF PREGNANCIES

REGISTER NO. WARD NO.

DEPART./SERVICE

RELATIONSHIP TO SPONSOR

RECORDS MAINTAINED AT

SPONSOR'S NAMEFIRST MI

SPONSOR'S ID NUMBER (SSN or Other)

HOSPITAL OR MEDICAL FACILITY

TELEPHONE (Work)AREA CODE NUMBER EXT.

PRIMARY PROVIDER/GROUP

HUSBAND/FATHER OF BABYNAME

LAST

STANDARD FORM 533 (REV. 12-1999) Prescribed by GSA/ICMR FMR (41 CFR) 101-11.203

PRENATAL AND PREGNANCY Medical Record

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex)

NSN 7540-00-634-4276

USE OF TOBACCONUMBER OF CIGARETTES

PER DAY

PRIOR TO PREGNANCY NOW

NO. OF YEARS SMOKED

USE OF ALCOHOLNUMBER OF DRINKS PER DAY

PRIOR TO PREGNANCY

NOW

NO. OF YEARS DRINKING

STANDARD FORM 533 (REV. 12-1999) PAGE 2

PAST MEDICAL HISTORY

ITEM O NEG + POS

DETAIL POSITIVE REMARKS (Include Date and Treatment) ITEM O NEG

+ POSDETAIL POSITIVE REMARKS (Include Date and Treatment)

DIABETES

HYPERTENSION

HEART DISEASE

AUTOIMMUNE DISORDER

KIDNEY DISEASE/UTI

PSYCHIATRIC

NEUROLOGIC/ EPILEPSYHEPATITIS/LIVER DISEASEVARICOSITIES/ PHLEBITISTHYROID DYSFUNCTIONTRAUMA/DOMESTIC VIOLENCEHISTORY OF BLOOD TRANSFUSION

D (RH) SENSITIZED

PULMONARY (TB, ASTHMA)

ALLERGIES (DRUGS)

BREAST

HISTORY OF ABNORMAL PAPUTERINE ANOMALY/ DES

INFERTILITY

RELEVANT FAMILY HISTORY

USE OF STREET DRUGS

COMMENTS/COUNSELING

AMOUNT PER DAYPRIOR TO PREGNANCY

NOW

NO. OF YEARS USE

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

OPERATIONS/HOS- PITALIZATIONS (Year and Reason)

GYN SURGERY

OTHER (Specify)

ANESTHETIC COMPLICATIONS

GENETICS SCREENING/TERATOLOGY COUNSELING (Includes Patient, Baby's Father, or anyone in Either Family)

ITEM ITEMPATIENT'S AGE IS GREATER THAN 35 YEARS

CONGENITAL HEART DEFECTDOWN SYNDROME

TAY-SACHS (E.G., JEWISH, CAJUN, FRENCH CANADIAN)

SICKLE CELL DISEASE OR TRAIT (AFRICAN)

HEMOPHILIA

MUSCULAR DYSTROPHYCYSTIC FIBROSIS

HUNTINGTON CHOREARECURRENT PREGNANCY LOSS OR A STILLBIRTH

IF YES, WAS PERSON TESTED FOR FRAGILE X

OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER

MATERIAL METABOLIC DISORDER *E.G., INSULIN-DEPENDENT DIABETES, PKU)

PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE

MEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST MENSTRUAL PERIOD

IF YES, LIST AGENT(S)

ANY OTHERCOMMENTS/COUNSELING

THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR ASIAN BACKGROUND (MCV IS LESS THAN 80)

MENTAL RETARDATION/AUTISM

NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA, OR ANENCEPHALY)

YES NO YES NO

OTHER

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; IDNo. or SSN; Sex; Date of Birth; Rank/Grade)

WARD NO.REGISTER NO.


INFECTION HISTORYITEM ITEM

HIGH RISK HEPATITIS B/IMMUNIZEDLIVE WITH SOMEONE WITH TB

EXPOSED TO TB

PATIENT OR PARTNER HAS HISTORY OF GENITAL HERPES

SACRUM

SUBPUBIC ARCH

GYNECOID PELVIC TYPE

DRUG ALLERGY RELIGIOUS/CULTURAL CONSIDERATIONS

RESULT

ANESTHESIA CONSULT PLANNED

YES NO

PROBLEMSMEDICATION LIST

TYPE START DATE STOP DATEPLANS

ESTIMATED DELIVERY DATE (EDD)CONFIRMATION

ACTION DATE WEEKS EDD

LMPINITIAL EXAM

ULTRASOUND

QUICKENINGFUNDAL HT. AT UMBIL.FHT W/FETOSCOPEULTRASOUND

INITIALED BY

18-20 WEEK UPDATEACTION ORIG. DATE WEEKS NEW DATE FINAL EDD

INITIALED BY

INITIAL EDD

PRESENT WEIGHT

RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIODHISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS

YES NOYES NO

COMMENTS

INTERVIEWER'S SIGNATURE

COMMENTS (List type and explain abnormality)

INITIAL PHYSICAL EXAMINATIONPRE-PREGNANCY WEIGHT HEIGHT BPEXAM DATE

HEART

ABDOMEN

EXTREMITIES

SKIN

LYMPH NODES

RECTUM

ITEM

HEENT

FUNDI

TEETH

THYROID

BREASTS

LUNGS

ABNORMALNORMAL

CHECK ONEITEM

VULVA

VAGINA

CERVIX

NORMAL

NORMAL

NORMAL

NORMAL

AVERAGE

CONCAVE

NORMAL

YES

CONDYLOMA

LESIONS

FIBROIDS

BLUNT

ANTERIOR

NARROW

CM

NO. OF WEEKS:

DISCHARGE

LESIONS

INFLAMMATION

INFLAMMATION

MASS

NO

PROMINENT

STRAIGHT

WIDE

NO

REACHED

UTERUS SIZE

ADNEXA

DIAGONAL CONJUGATE

SPINES

NSN 7540-00-634-4276

PROBLEMS COMMENTS

VISITS

DATE

PRETERM LABOR SIGNS/SYMPTOMS

PRESENT ABSENT

WE

EK

S G

ES

T.

(BE

ST

ES

T.)

FUN

DA

L H

EIG

HT

(CM

)

PR

ES

EN

TATI

ON

FHR

FETA

L M

OV

EM

EN

T

CE

RV

IX E

XA

M

(DIL

./EFF

./ S

TA.)

ED

EM

A

PR

OV

IDE

R

(Initi

als)

WE

IGH

T

NE

XT

AP

PO

INT-

M

EN

T (D

ate)

COMMENTSBLOOD PRES- SURE

URINE (GLUCOSE/ ALBUMIN)


NSN 7540-00-634-4276

ID NUMBERMIDDLE INITIALFIRST NAMELAST NAME

LABORATORY AND EDUCATION

BLOOD TYPE

D (RH) TYPE

PAP TEST

HIV COUNSELING/TESTING

ANTIBODY SCREEN

RUBELLA

VDRL

HCT/HGB

URINE CULTURE/SCREEN

HB s AG

ULTRASOUND

MSAFP/MULTIPLE MARKERS

AMNIO/CVS

KARYOTYPE

AMNIOTIC FLUID (AFP)

NORMALABNORMAL

POSITIVE

NEGATIVEDECLINED

HGB ELETROPHORESIS

PPD

CHLAMYDIA

GC

TAY-SACHS

OTHER

SSAS AC

AF TA2

AA

SC

46, XX

46, XY

OTHER

PERCENTAGE G/DL

OTHER

NORMAL ABNORMAL

TYPE DATE

INIT

IAL

LAB

SO

PTI

ON

AL

LAB

S8-

18 W

EE

K L

AB

S

(Whe

n in

dica

ted/

elec

ted)

RESULT REVIEWED COMMENTS/ADDITIONAL LAB

A

AB

B

O

WARD NO.REGISTER NO.PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)

NSN 7540-00-634-4276


COMMENTS/COUNSELING

TYPE DATE RESULT REVIEWED COMMENTS/ADDITIONAL LAB

HCT/HGB

DIABETES SCREEN

GTT (If screen abnormal)

D (RH) ANTIBODY SCREEN

D IMMUNE GLOBULIN (RHG) GIVEN (28 WEEKS)

HCT/HGB (Recommended)

ULTRASOUND

VDRL

GC

CHLAMYDIA

GROUP B STREP (35-37 WEEKS)

COUNSELED

LIFESTYLE, TOBACCO, ALCOHOL

TRAVEL

CIRCUMCISION

VBAC COUNSELING

TUBAL STERILIZATION

POSTPARTUM BIRTH CONTROL

ENVIRONMENTAL/WORK HAZARDS

NEWBORN CAR SEAT

ANESTHESIA PLANS

TOXOPLASMOSIS PRECAUTIONS (CATS/RAW MEAT)

CHILDBIRTH CLASSES

PHYSICAL/SEXUAL ACTIVITY

LABOR SIGNS

NUTRITION COUNSELING

BREAST OR BOTTLE FEEDING

PERCENTAGE G/DL

1 HOUR

SIGNATURE

PERCENTAGE G/DL

FBS

2 HOUR

1 HOUR

3 HOUR

TYPE COMMENTS COMMENTSTYPEPLANS/EDUCATION

RESULTS TUBAL STERILIZATIONDATE CONSENT SIGNED INITIALS

NSN 7540-00-634-4276


24-2

8 W

EE

K L

AB

S32

-36

WE

EK

LA

BS


PROGRESS NOTES

SUPPLEMENTAL VISITS

DATE

PRETERM LABOR SIGNS/SYMPTOMS

PRESENT ABSENT

WE

EK

S G

ES

T.

(BE

ST

ES

T.)

FUN

DA

L H

EIG

HT

(CM

)

PR

ES

EN

TATI

ON

FHR

FETA

L M

OV

EM

EN

T

CE

RV

IX E

XA

M

(DIL

./EFF

./ S

TA.)

ED

EM

A

PR

OV

IDE

R

(Initi

als)

WE

IGH

T

NE

XT

AP

PO

INT-

M

EN

T (D

ate)

COMMENTSBLOOD PRES- SURE

URINE (GLUCOSE/ ALBUMIN)

NSN 7540-00-634-4276


WARD NO.REGISTER NO.PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)

NSN 7540-00-634-4276


PROGRESS NOTES


CESAREANVAGINAL

DISCHARGE/POSTPARTUM

DELIVERY INFORMATIONDELIVERY DATE

DELIVERY AT (Weeks)

TYPE OF DELIVERY

STILLBIRTHIN HOSPITAL

NEONATAL DEATHOTHER

COMPLICATIONS/ANOMALIES

SIGNATURE OF PROVIDER (AS REQUIRED)

LABORAUGMENTED

NO LABOR

SPONTANEOUS

INDUCED

ANESTHESIAGENERAL

OTHER

NONE

LOCAL/PUDENDAL

EPIDURAL

SPINAL

INTERIM CONTACTSDATE COMMENT

SVD

VACUUM

FORCEPS

EPISIOTOMY

LACERATIONS

VBAC

PRIMARYFOR

POSTPARTUM COMPLICATIONSNONE HEMORRHAGE INFECTION HYPERTENSION OTHER:

DISCHARGE INFORMATIONDISCHARGE DATE

MATERNALHB/HCT LEVEL

FEEDING METHOD

BREAST BOTTLE

CONTRACEPTIVE METHOD (If applicable) MEDICATIONS

DIAGNOSTIC STUDIES PENDING

SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS

ASTHMA

DIABETES

HYPERTENSION

OTHER

FOLLOW-UP APPOINTMENT

DATE LOCATION

REMARKSIMMUNIZATIONS GIVEN

D (Rho)(D)) IMMUNE GLOBULIN

DIABETES

OTHER:

NEONATALSEX

FEMALE

MALE

CIRCUMCISION

YES NOBIRTH WEIGHT NAME OF BABY

CLASSICAL REPEAT - ELECTIVE

REPEAT-FAILED VBAC

LOW TRANSVERSE

LOW VERTICAL

DISPOSITIONHOME WITH MOTHER

TRANSFER


PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)

REGISTER NO. WARD NO.

NSN 7540-00-634-4276

YES NO

YES NO

POSTPARTUM VISITSDATE ALLERGIES

LAB STUDIES REQUESTED MEDICATIONS/CONTRACEPTION

MEDICATIONS/CONTRACEPTION DISPENSED

CONTRACEPTIVE METHOD

HGB/HCT LAST PAP SMEAR (Date)

INTERIM HISTORY

INTERVAL CARE RECOMMENDATIONSFOR GENERAL HEALTH PROMOTION

FOR REPRODUCTIVE HEALTH PROMOTION

RETURN VISIT (Date)

REFERRALS

EXAMINED BY

PHYSICAL EXAMBP WEIGHT PAP SMEAR

ITEM COMMENTS

BREASTS

ABDOMEN

EXTERNAL GENITALS

VAGINA

CERVIX

UTERUS

ADNEXA

RECTAL-VAGINAL

ABNORMALNORMAL

FEEDING METHOD

COMMENTS

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

NSN 7540-00-634-4276


COMMENTS (Continue on back if needed)


WARD NO.REGISTER NO.PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. (SSN or other); hospital or medical facility)

NSN 7540-00-634-4276

medical record prenatal and pregnancy

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