GREENVILLE MIDWIFERY CARE

NAME:

___________________________________________________
PRENATAL CARE RECORD (Page 1 of 3 )
____________________________________________________

Your age:

Race:

Your DOB:

Country of birth:

MR#:

Phone (primary): ___________________________ Other:

__________________________
Email:

Religious practices / cultural or ethnic considerations:

Highest level of education:

Name of partner / father of baby (FOB):

Occupation:

Relationship status: Married to father of baby

Living with father of baby in a long-term committed relationship
Single, father of baby not involved
Single, father of baby involved, supportive
Divorced
Widowed Other:
_____________________________________________
FOBs age:
Race:
Occupation:

Primary care provider / Phone:

Dentist / Phone:

Phone (primary):

Phone (other):

Name of other emergency contact:

__________________________
Phone:
_________________________________________________
Relationship:
____________________________________________

Ages, names, and health status of FOBs other

children (if applicable):

Briefly tell us your reasons for choosing our

practice and how you found out about us.

Please list the ages and names of all members in your

household:

MENSTRUAL HISTORY:
1st day of last menstrual period ______________________
How often do you have periods? Every __________ days
Was this a normal, regular, on-time, normal period for you? Yes No ______________________________________
Were you using any methods to prevent pregnancy? No Yes _____________________________________________
Did you conceive using infertility treatment? No Yes __________________________________________________
Date of 1st positive pregnancy test ____________________
Any spotting or bleeding since LMP? __________________
HISTORY SINCE LMP:
Since your last menstrual period, have you been exposed to any of the following:
X-Rays or exposure to hazardous chemicals or other substances
_______________________________________________________
Rash or viral illnesses Hospitalizations or emergency room visits
_____________________________________________________
Travel outside the country? _____________________________________________________________________________________
Have you experienced any major life changes / stressors (moving, death in family, loss of job, etc)
____________________________
______________________________________________________________________________________________________________

JFPCNM01/2013

Amt / Day
prior to
pregnancy

Amt / day
now

# Years
Use

Attempts to
quit?

List any medications (prescription or over-thecounter), supplements, herbal preparations

since LMP.

Tobacco use
Alcohol
consumption
llicit (street)
drugs

PRENATAL CARE RECORD (page 2 of 3)

___________________________________________________

Name:

PAST MEDICAL HISTORY

Do you have a history of any of the
following? Indicate in the column with
(+) sign or (-) sign.

1.
2.

Diabetes
High blood pressure

3.
4.

Anemia
Blood disorders or blood
clots
Varicose veins
Thyroid dysfunction
Heart disease/ Rheumatic
fever
Kidney disease or frequent
urinary tract infections

5.
6.
7.
8.

9.

Detail + remarks.
Include date and
treatment

Condition:

0
NEG
+
POS

Detail + remarks
include date &
treatment

22. Surgeries (non-gyn)

23. Anesthesia
complications
GYNECOLOGICAL HISTORY
24. Breast conditions
25. Endometriosis
26. Painful or heavy periods
27. Abnormal pap smears
28. Infertility
29. Gynecological
procedures
30. Uterine or cervical

Hepatitis or liver disease

abnormalities

10. Seizure disorder/ Epilepsy

11. Asthma or pulmonary
disease
12. Tuberculosis or + PPD skin
test
13. Autoimmune disorders

31. HPV or genital warts

32. Chlamydia or gonorrhea
33. Genital Herpes
IMMUNIZATION
HISTORY:
34. Chicken pox or vaccine

14. Digestive disorders GERD or IBS

15. Migraine headaches

35. Date of pertussis

vaccine
37. Date of last tetanus
shot
38. Seasonal influenza
vaccine
ALLERGIES:
FAMILY HISTORY:
1. Diabetes

16. Arthritis / Chronic pain

17. Cancer
18. HIV
19. Major depression /
Anxiety /
Psychiatric disorders
20. Major accidents / injuries /
Hospitalizations
21. D (Rh) sensitization
22. Blood transfusion

2. Heart Disease, Stroke,

High blood pressure
3. Cancer
4. Psychiatric disorders

PLEASE LIST ALL PRIOR PREGNANCY OUTCOMES, BEGINNING WITH THE MOST RECENT:
JFPCNM01/2013

Ye
ar

Place
of birth

Birth
setting
Birth
Center,
Home,
Hospital

# Wks
gestatio
n

Length of
Labor

Type of
Delivery

M/F

Infants
weight

Complications
of during
pregnancy or
birth?

Duration
of
breastfee
ding

Comments (number and explain):

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
... Patients stop here
.
Prenatal Care Record (page 3 of 3)
______________________________________________

Name:

PHYSICAL EXAM
DATE: ___________________
_______ BMI: ________

BP: __________

HR: _________

HT: __________

1. HEENT

NML

ABN

2. FUNDI

NML

ABN

3. TEETH

NML

ABN

12. LYMPH
NODES
13. EXT.
GENITALIA
14. ANUS

4. THYROID
5. BREASTS

NML
NML

ABN
ABN

15. VULVA
16. VAGINA

6. LUNGS
7. HEART

NML
NML

ABN
ABN

17. CERVIX

8. ABDOMEN

NML

ABN

18. UTERUS

9.
EXTREMITIES
10. SKIN
11. TATTOOS
COMMENTS:

NML

ABN

19. ADNEXAE

HEMORRHOID LESIONS
S
NML
LESIONS
NML
INFLAMMATIO
DISCHARGE
N
WET PREP / KOH
NML
INFLAMMATIO DISCHARG
N
SIZE ______ WKS
POSITION
TENDER
______
NML
MASS
TENDER

NML

ABN

2O. RECTUM
21. PELVIS

DEFERRED
ADEQUATE

JFPCNM01/2013

NML

ABN

NML

LESIONS

WT. AT LMP

NML

NML
PROVEN

ABN
ABN

Signature / Date

ROS / Health history reviewed:

_______________________________________________________________________________
Genetic screening assessment reviewed:
________________________________________________________________________
Nutritional Assessment / Diet Hx reviewed:
_____________________________________________________________________
Edinburgh Depression Screening tool reviewed: Score _________
________________________________________________
Pregnancy support assessment reviewed:
_______________________________________________________________________

PREGNANCY ASSESSMENT:
1. _________________________________________
TOLAC and VBAC
________________________________________
CF scrn
2. ________________________________________
________________________________________
3. ________________________________________
________________________________________
4. _________________________________________
__________________________________
_________________________________________
vitamins

PREGNANCY / BIRTH PLANS:

Normal pregnancy guideline
New OB prenatal panel

HbsAg

Planned
HIV screen

US dates / viability NT screen

Pap w/Reflex HPV
HPV DNA GC/CT screen
MFM consult / genetic counseling ___________________
Nutritional counseling referral ______________________
Medical records release
Prenatal vitamins Rx given

Taking OTC

Other:
____________________________________________________________________________________________________

Education and Counseling performed - see teaching check list

weeks

Return to clinic _______ days

__________________________________________________________
CNM
signature / date

JFPCNM01/2013