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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