PRENATAL RECORD
Patient Name: Samantha Young
Date of Birth: 12/16/___
Age: 35
Med Record #: 320004
Page 1 of 3 pages
Patient Information
Street Address: 124 Front St SE
Single:
Divorced:
Home phone #: (616) 555-0004
Cell phone #: (616) 555-1004
Work phone # : None
Husband/Father of Baby
Name: Ralph
Involved: X
Not Involved:
Occupation
Homemaker:
Student:
Outside Work:
Emergency Contact
Ralph
Relationship: Husband
Phone #: (616) 555- 0004
Marital Status
Married: X
Separated:
Widowed:
Education (last grade completed)
BA in music
Reproductive History
LMP
10
weeks
ago
EDC
Gravida
Para
Term
Preterm
2
0
3
Date
8 years ago
5 years ago
Abortions
Spont Elect Ectop
0
0
0
Living
2
Prior Pregnancies
Delivery
Complications
NSD
None
NSD
Forceps
Gestation
39
38
Deceased
Outcome
Girl, 8lb8oz
Girl 9lb10oz
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: today
Results:
Type
GC
Chl
HIV
Positive:
Negative:
Declined:
Cultures
Date
Results
Today
today
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
Cigarettes
Years
Smoked:
Prior to PG:
0
Now:
0
Use of Alcohol (ETOH)
Number of drinks per day # of
(average)
Years
Drinking:
15 years
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: Samantha Young
Date of Birth: 12/16/___
Age: 35
Med Record #: 320004
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
BCP w/in 90 days
of conception
Hospitalizations
0
0
+
Surgeries
+
Previous deliveries
Syphilis:
0
HIV:
TB:
0
0
Pulmonary/Asthma
Neuro/Epilepsy
0
Hepatitis/GI
0
Psychiatric
0
Hepatitis B:
0
7 years ago Appy
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
0
0
0
Immunization Status
MMR: 3 doses received
Varicella: xx-xx-xx
Td Booster: xx-xx-xxx
(at age 13)
xx-xx-xx; xx-xx-xx; xx-xx-xx
Polio: 3 doses received
Hepatitis B: Immunized
Flu:
xx-xx-xx; xx-xx-xx; xx-xx-xx
Initial Pregnancy Examination [ N = Negative/Normal/None; P = Positive]
Date: Today
Height:
Vital signs T =
P=
Planned Pregnancy? Yes
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
Uterus
P
Adnexa
N
Rectum
N
R=
Pre-Preg Weight:
Current Weight:
Ethnicity:
pounds
pounds
American Indian
BP =
Gestational Age by LMP
weeks
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
Goodell’s/Chadwick’s
signs noted. Uterus is soft
and enlarged – about 10
week size
PRENATAL RECORD
Patient Name: Samantha Young
Date of Birth: 12/16/___
Age: 35
Med Record #: 320004
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: Samantha Young
Date of Birth: 12/16/___
Age: 35
Progress Notes
Date
xx-xx-xx
Today
Notes
Med Record #: 320004
Page 4 of 3 pages