PRENATAL RECORD
Patient Name: Roberta Gomez
Date of Birth: 17 yrs ago
Med Record #: 555555555
Age: 17
Page 1 of 3 pages
Patient Information
Street Address:
Single: X
Divorced:
Home phone #: (616) 555-1005
Cell phone #: (616) 555-2005
Work phone # : None
Husband/Father of Baby
Name: Sam
Involved: X
Not Involved:
Occupation
Homemaker:
Student: X Outside Work:
Emergency Contact
Maria Gomez
Relationship: mother
Phone #: (616) 555- 5005
Marital Status
Married:
Separated:
Widowed:
Education (last grade completed)
11th grade
Reproductive History
LMP
EDC
Date
Gravida
1
Para
Term
Preterm
0
Abortions
Spont Elect Ectop
Living
Prior Pregnancies
Delivery
Complications
Gestation
Deceased
Outcome
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:
Cultures
Date
Results
xx-xx-xx
xx-xx-xx
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
Type of Tobacco Used:
# of
none
Years
Smoked:
Prior to PG:
Now:
Use of Alcohol (ETOH)
Number of drinks per day # of
(average)
Years
Drinking:
0
Prior to PG: Now:
0
0
Street Drugs
Type: Denies Use
# of
years
Use:
None
Prior to
Now:
PG:
None
None
PRENATAL RECORD
Patient Name: Roberta Gomez
Date of Birth: 17 yrs ago
Med Record #: 555555555
Age: 17
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
States FOB is only sex
partner in her lifetime
Syphilis:
0
HIV:
TB:
0
0
Pulmonary/Asthma
0
0
Neuro/Epilepsy
0
0
Hepatitis/GI
0
Surgeries
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
0
Hepatitis B:
0
0
0
0
Immunization Status
Td Booster: xx-xx-xxx
MMR: 3 doses received
Varicella: xx-xx-xx
(at age 12)
xx-xx-xx; xx-xx-xx; xx-xx-xx
Polio: 3 doses received
Hepatitis B:
Flu:
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:
105 pounds
pounds
Gestational Age by LMP
Vital signs T = ; P = ; R = ; BP =
Planned Pregnancy?
Physical Exam
Alert/Cooperative
N
HEENT
N
Thyroid/Neck
N
Lungs
N
Heart/Pulses
N
Breasts
N
Abdomen
N
Extremities/Skin
N
Pelvic Exam
Vulva
N
Vagina
N
Cervix
P
Goodell’s/Chadwick’s
Uterus
P
signs noted. Uterus is soft
Adnexa
N
and enlarged – about 14
week size
Rectum
N
Present Pregnancy History
Nausea/Vomiting
P
Vaginal Bleeding
N
Vaginal Discharge
N
Urinary S/S
N
Constipation
N
Fever/Rash
N
Infection
N
Other
N
Assessment/Plan
Ethnicity:
Hispanic
weeks
PRENATAL RECORD
Patient Name: Roberta Gomez
Date of Birth: 17 yrs ago
Med Record #: 555555555
Age: 17
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
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: Roberta Gomez
Date of Birth: 17 yrs ago
Med Record #: 555555555
Age: 17
Progress Notes
Date
xx-xx-xx
Today
Notes
Page 4 of 3 pages