463 Appendix A American College of Obstetricians and Gynecologists’ Antepartum Record and Postpartum Form MENSTRUAL HISTORY LMP DEFINITE APPROXIMATE (MONTH KNOWN) MENSES MONTHLY YES NO FREQUENCY: Q _________ DAYS MENARCHE: _______________ (AGE ONSET) UNKNOWN NORMAL AMOUNT/DURATION PRIOR MENSES: _________ DATE ON BCP AT CONCEPT YES NO hCG + _____/_____/_____ FINAL: ____________ PAST PREGNANCIES (LAST SIX) DATE LENGTH PRETERM MONTH/ GA OF BIRTH SEX TYPE OF PLACE OF LABOR COMMENTS/ YEAR WEEKS LABOR WEIGHT M/F DELIVERY ANES DELIVERY YES/NO COMPLICATIONS MEDICAL HISTORY Patient Addressograph A N TEPARTUM RE CO R D (FORM A, page 1 of 12) DATE: NAME: LAST FIRST MIDDLE ID #: HOSPITAL OF DELIVERY: NEWBORN CARE PROVIDER: REFERRED BY: FINAL EDD: PRIMARY PROVIDER/GROUP: BIRTH DATE: AGE: RACE: MARITAL STATUS: MONTH DAY YEAR S M W D SEP OCCUPATION: EDUCATION: LANGUAGE: ETHNICITY: HUSBAND/DOMESTIC PARTNER: PHONE: FATHER OF BABY: PHONE: ADDRESS:___________________________________________________________________________ ZIP: _______________PHONE: _________________________ (1)___________________________ (2) E-MAIL: INSURANCE CARRIER/MEDICAID #: POLICY #: EMERGENCY CONTACT: PHONE: TOTAL PREG: FULL TERM: PREMATURE: AB, INDUCED: AB, SPONTANEOUS: ECTOPICS: MULTIPLE BIRTHS: LIVING: (LAST GRADE COMPLETED) Neg. DETAIL POSITIVE REMARKS + Pos. INCLUDE DATE & TREATMENT Neg. DETAIL POSITIVE REMARKS + Pos. INCLUDE DATE & TREATMENT COMMENTS: ( ) ADDRESS: Version 7. Copyright 2011 The American College of Obstetricians and Gynecologists (AA128) 12345/54321 A. DRUG/LATEX ALLERGIES/ REACTIONS B. ALLERGIES (FOOD, SEASONAL, ENVIRONMENTAL) 1. NEUROLOGIC/EPILEPSY 2. THYROID DYSFUNCTION 3. BREAST DISEASE 4. PULMONARY (TB, ASTHMA) 5. HEART DISEASE 6. HYPERTENSION 7. CANCER 8. HEMATOLOGIC DISORDERS 9. ANEMIA 10. GASTROINTESTINAL DISORDERS 11. HEPATITIS/LIVER DISEASE 12. KIDNEY DISEASE/UTI 13. VARICOSITIES/PHLEBITIS 14. DIABETES (TYPE 1 OR TYPE 2) 15. GESTATIONAL DIABETES 16. AUTOIMMUNE DISORDERS 17. DERMATOLOGIC DISORDERS 18. OPERATIONS/HOSPITALIZATIONS (YEAR & REASON) 19. GYN SURGERY 20. ANESTHETIC COMPLICATIONS 21. HISTORY OF BLOOD TRANSFUSIONS 22. INFERTILITY 23. ASSISTED REPRODUCTIVE TECHNOLOGY 24. UTERINE ANOMALY/DES 25. HISTORY OF ABNORMAL PAP 26. HISTORY OF STI 27. PSYCHIATRIC ILLNESS 28. DEPRESSION/POSTPARTUM DEPRESSION 29. TRAUMA/VIOLENCE 30. TOBACCO (AMT/DAY) 31. ALCOHOL (AMT/WK) 32. ILLICIT/RECREATIONAL DRUGS (USES/WK) 33. RELEVANT FAMILY HISTORY 34. OTHER # YEARS PREPREG PREG USE
Previous Page Next Page