Specifically ask about UTI’s/bladder infections

 

Allergies         drugs   foods   latex

 

            Diabetes

            Hypertension

            Birth Defects MOB family                FOB family

Previous births

            NSVD, Preterm, Hypertension, Other Complications

            Where did births take place? Home? Country? Hospital?

            STI, Abnormal PAP, Yeast Infections

            Other

            Planned/surprise (unplanned)

            FOB supportive

            Lives with?

            Regular Seatbelt Use

            Tobacco (see questions on reverse side)

            Drugs

            ETOH

            DV Screen

            School/Work

            Medicaid:  Presumptive   Baby Love   Regular   None     Private Insurance

            WIC (Supplemental food program)

            MCC (maternity care coordinator often called “baby love worker”)

            N&V frequency, weight gain?  Meds?

            Headaches-frequency, meds?  Quickening/fetal movement

 

            Quickening at 18-20 weeks or regular fetal movement

            Abnormal Discharge/bleeding

            Cramping/Contractions

            Problems/Questions

            Labs Today/Schedule ultrasounds/tests

            Return to clinic (next appointment)

            Labs next visit

            Schedule Ultrasound, genetic counseling, induction, cesarean etc.