581
The American College of Obstetricians
and Gynecologists’ Antepartum
Record and Postpartum Form
^159 ^161 ^233 ^234 ^280 ^297
Appendix A
Version 8. Copyright 2016 The American College of Obstetricians and Gynecologists (AA128) 12345/09876
Patient Addressograph
ANTEPARTUM
RECORD
(FORM
A,
page
1
of
12)
# Years
Prepreg Preg
Use
Detail Positive Remarks
P* F*
Include Date & TreatmentTreatment&
COMMENTS:
*P=
Personal F= Family
at conception
LAST FIRST MIDDLE
ANTEPARTUM RECORD
Detail Positive Remarks
P* F*
Include Date & Treatment
P
*
F
*
Address:
Zip: Phone: (1) (2)
E-Mail:
Insurance Carrier/Medicaid #:
Policy #:
Emergency Contact: Phone:
A. Drug/Latex Allergies/
Reactions
B. Allergies (Food, Seasonal,
Environmental)
1. Neurologic/Epilepsy
2. Thyroid Dysfunction
3. Breast Disease/Breast
Surgery
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. Deep Vein Thrombosis
14. Diabetes (Type 1 Or Type 2)
15. Gestational Diabetes
16. Autoimmune Disorders
Date: ID #:
Detail Positive Remarks
Include Date
Birth Date: Age: Race: Marital Status:
S M W D Sep
Occupation:
Education:
(Last Grade Completed)
Language: Ethnicity:
Partner: Phone:
Father Of Baby: Phone:
Total Preg: Full Term: Premature: Ab, Induced: Ab, Spontaneous: Ectopics: Multiple Births: Living:
Hospital of Delivery:
Name:
Newborn Care Provider: Referred By:
Primary Care Provider/Group: Address:
Final EDD:
Menstrual History
Lmp Definite Approximate (Month Known)
Duration: Q _________ Days Frequency: Q _________ Days Menarche: _______________ (Age Onset)
Unknown Normal Amount/Duration
Final: ____________
Prior Menses: _________ Date Contraception Yes No Hcg +
_____/_____/_____
Past Pregnancies (Last Five)
Date Length Lactation
Month/ GA Of Birth Sex Type Of Place Of Breastfeeding Consult Needed Comments/
Year Weeks Labor Weight M/F Delivery Anes Delivery Duration Yes/No Complications
Medical History
17. Dermatologic Disorders
18. Operations/Hospitalizations
(Year & Reason)
19. Gyn Surgery
(Year & Reason)
20. Anesthetic Complications
21. History Of Blood
Transfusions
22. Infertility
23. Art (IVF Or FET)
24. History of Abnormal Pap
25. History of STI
26. Psychiatric Illness
27. Depression/Postpartum
Depression
28. Trauma/Violence
29. Tobacco (Smoked, Chewed,
ENDS, Vaped) (AMT/Day)
30. Alcohol (AMT/Wk)
31. Drug Use (Including
Opioids) (Uses/Wk)
32. Polycystic Ovary Syndrome
33. Other
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