PRENATAL RECORD Patient Name: Date of Birth: Monique Salter Med Record #: 320001 Age: 28 Page 1 of 3 pages Patient Information Street Address: Home phone #: (616) 555-0000 Cell phone #: (616) 555-0001 Work phone # : None Husband/Father of Baby Name: Gary Involved: YES Not Involved: Occupation Homemaker: Student: NO Outside Work: Teacher Emergency Contact Gary Relationship: husband Phone #: (616) 555- 1000 Marital Status Married: YES Separated: Widowed: Education (last grade completed) BA in Education Single: Divorced: Reproductive History LMP 12/07/2007 EDC Gravida 3 Date 4 years ago 2 years ago Para Term Preterm 2 0 Abortions Spont Elect Ectop 0 0 0 Prior Pregnancies Delivery Complications NSVD None NSVD None Gestation 40 38 Living Deceased 2 0 Outcome Boy, 8lb, 2 oz Girl, 6lb 12 oz Initial Laboratory Data (Date: xx-xx-xx) Blood Type: Rh: Rubella Immune: Non-Immune: Hemoglobin RPR/VDRL Positive: Negative: Hematocrit HBsAG Positive: Negative: GBS Positive: Negative: Pap Smear Date: xx-xx-xx Results: WNL (negative for malignancy) Type GC Chl HIV Positive: Negative: Declined: X Cultures Date Results xx-xx-xx Negative xx-xx-xx Negative 8-18 Weeks Laboratory Data Ultrasound Date: Results: Multiple Markers Test Date: Results: Amnio/CVS Date: Results: Karyotype 46, XX 46, XY Other: History of Substance Use Use of Tobacco Use of Alcohol (ETOH) Type of Tobacco Used: # of Number of drinks per day # of Cigarettes Years (average) Years Smoked: Drinking: 0 15 years Prior to PG: Now: Prior to PG: Now: occasional 0 Street Drugs Type: Denies Use # of years Use: None Prior to Now: PG: None None PRENATAL RECORD Patient Name: Date of Birth: Monique Salter Med Record #: 320001 Age: 28 Page 2 of 3 pages Past Medical History [ 0 = Negative / + = Positive and describe] Allergies: No Known Allergies (NKA) Gonorrhea: Chlamydia: HSV: HPV: 0 0 0 0 STD/HIV Risk 0 BCP w/in 90 days of conception Hospitalizations 0 + Surgeries States FOB is only sex partner in her lifetime Syphilis: 0 HIV: TB: 0 0 Pulmonary/Asthma 0 Neuro/Epilepsy + Hepatitis/GI 0 0 Psychiatric 0 Transfusions 0 Thyroid 0 Diabetes 0 0 HTN/Vascular 0 Cardiac Problems or Disease Kidney/ UTI 0 Varicosities/ Phlebitis Uterine Anomalies Or DES exposure Abnormal Pap Results Trauma/Domestic Violence Prior childbirth 0 Hepatitis B: 0 Migraines s aura 0 0 0 Immunization Status Td Booster: xx-xx-xxx MMR: 3 doses received Varicella: xx-xx-xx (at age 13) xx-xx-xx; xx-xx-xx; xx-xx-xx Polio: 3 doses received Hepatitis B: Flu: Not immunized xx-xx-xx; xx-xx-xx; xx-xx-xx Initial Pregnancy Examination [ N = Negative/Normal/None; P = Positive] Date: Today Height: Pre-Preg Weight: Current Weight: Ethnicity: 5’ 6” 145 pounds 145 pounds African American Vital signs T = 98.6; P = 64; R = 16; BP = 108/64 Gestational Age by LMP 12 weeks Planned Pregnancy? Yes Physical Exam Present Pregnancy History Alert/Cooperative N Nausea/Vomiting P Slight nausea, eating HEENT N Vaginal Bleeding N “OK” Thyroid/Neck N Vaginal Discharge N Lungs N Urinary S/S N Heart/Pulses N Constipation N Breasts N Fever/Rash N Abdomen N Infection N Extremities/Skin N Other N Pelvic Exam Assessment/Plan Vulva N Vagina N Cervix P Goodell’s/Chadwick’s Uterus P signs noted. Uterus is soft Adnexa N and enlarged – about 10 week size Rectum N PRENATAL RECORD Patient Name: Date of Birth: Monique Salter Med Record #: 320001 Age: 28 Page 3 of 3 pages Medication List Medications Ordered Type Prenatal vitamins 1 tab orally each day Date xx-xx-xx Script given to patient Notes Dispense one bottle of 60 capsules Refills: 4 Medications Administered in Office Name J. Geddes Type RhoGAM 300 mcg IM (if indicated) Mfg: Lot # Exp. Date: Influenza Vaccine 0.5 mL IM (Oct 1 – March 1) Mfg: Lot # Exp. Date Date/Site Provider Name PRENATAL VISITS Date xx-xx today Wks Gest 11 Weight (lbs) BP Urine/ Protein Urine/ Glucose Edema FHR Fundal Ht-cm Fetal Activity Pres PTL S/S Next Appt Ini PRENATAL RECORD Patient Name: Date of Birth: Monique Salter Med Record #: 320001 Age: 28 Page 4 of 3 pages Progress Notes Date xx-xx-xx Today Notes Presented for 1st prenatal visit and initial exam. Pt appears to be stated age. C/o fatigue and some nausea. No other complaints. Excited about pregnancy. Husband also here.