Antenatal Record 1 PDF

Antenatal Record 1 Ontario Medical In conjunction with the Ministry of Health Association and Long-Term Care Patient’s Last Name...

Antenatal Record 1 Ontario Medical In conjunction with the Ministry of Health Association and Long-Term Care Patient’s Last Name Patient’s First Name Address – number, street name Apt/Suite/Unit City/Town Province Postal Code Partner’s Last Name Partner’s First Name Telephone - Home Telephone - Work Language Partner’s Occupation Partner’s Educational level Age Date of birth Age Occupation Educational level Ethnic or Racial backgrounds: Mother / Father YYYY/MM/DD OHIP No. Patient File No. Marital status Birth attendant Newborn care Family Physician Allergies or Sensitivities (describe reaction details) Medications/Herbals Pregnancy Summary LMP YYYY/MM/DD Certain Yes No EDB (by dates) Final EDB Dating Method Cycle q _____ Regular Yes No Dates Contraceptive type Last used YYYY/MM/DD T1 US T2 US Gravida Term Premature Abortuses Living ART (e.g. IVF) Obstetrical History No. Year Sex Gest. age Birth Length of Place Type of Comments regarding pregnancy and birth M/F (weeks) weight labour of birth delivery Medical History and Physical Exam (provide details in comments) Initial Laboratory Investigations Current Pregnancy Genetic History Family History Test Result Test Result 1. Bleeding Y / N 22. At risk population Y/N 38. At risk population Y/N 2. Nausea, vomiting Y / N (e.g.: Ashkenazi, consanguinity , CF, (e.g.: DM, DVT/PE, PIH/HT, Hb HIV 3. Smoking ___cig/day Y / N sickle cell, Tay Sachs, thalassemia) postpartum depression, thyroid) 4. Alcohol, street drugs Y / N Family history of: MCV Counseled and test declined 5. Occup/Environ. risks Y / N 23. Developmental delay Y/N Physical Examination Y/N ABO Last Pap 6. Dietary restrictions Y / N 24. Congenital anomalies Ht._______ Wt._______ 7. Calcium adequate Y / N 25. Chromosomal disorders Y / N Rh YYYY/MM/DD 8. Preconceptual folate Y / N 26. Genetic disorders Y/N BMI______ BP _______ Antibody Screen GC/Chlamydia Medical History Infectious Disease 39. Thyroid Rubella immune Urine C&S 9. Hypertension Y/N 27. Varicella susceptible Y/N N / Abn 10. Endocrine Y/N 28. STDs / HSV / BV Y/N 40. Chest N / Abn HBsAg 11. Urinary tract Y/N 29. Tuberculosis risk Y/N 41. Breasts N / Abn 42. Cardiovascular VDRL 12. Cardiac/Pulmonary Y/N 30. Other Y/N N / Abn 13. Liver, hepatitis, Gl Y/N 43. Abdomen N / Abn Sickle Cell 14. Gynaecology/ Breast Y/N Psychosocial 44. Varicosities / Extrm. N / Abn 15. Hem./Immunology Y/N 31. Poor social support Y/N 45. External genitalia N / Abn Prenatal Genetic Investigations Result 16. Surgery Y/N 32. Relationship problems Y/N 46. Cervix, vagina N / Abn a) All ages-MSS, IPS, FTS 17. Blood transfusion Y/N 33. Emotional/Depression Y/N 47. Uterus N / Abn 18. Anaesthetic compl. Y/N 34. Substance abuse Y/N 48. Size: ______ weeks b) Age ≥ 35 at EDB-CVS/amnio 19. Psychiatric Y/N 35. Family violence Y/N 49. Adnexae N / Abn 50. Other c) If a or b declined, or twins, then MSAFP 20. Epilepsy/ Neurological Y/N 36. Parenting concerns Y/N N / Abn 21. Other Y/N 37. Relig. / Cultural issues Y/N d) Counseled and test declined, or too late Comments Signature Date Signature Date 4293-64 (05/03) Canary – Mother’s chart – forward to hospital Pink – Attendant’s copy White – infant’s chart 7530-5624  A Guide to Pregnancy Assessment In the event of maternal transfer, please photocopy the front sheet and send to referral hospital. This assessment system is intended as a basis for planning the on-going management of the pregnancy and should reflect local resources. The risk factors or problems listed below are intended as examples only. Healthy Pregnancy, no predictable risk: No pregnancy complications now or in the No prior perinatal morbidity or mortality past Fetal growth adequate No significant maternal medical disease Pregnancy at risk: The fetus/mother may be at risk. Closer observation of the pregnancy may be necessary. In addition, consultation with an appropriate specialist (obstetrician, internist, pediatrician, etc.) may also be necessary. These patients may be managed by continuing collaborative care and birth in an obstetrical unit with intermediate level nursing facilities OR they may be returned to the care of the referring provider with a suggested plan of management for the remainder of the pregnancy. Maternal factors: Current pregnancy complicated by: Diabetes, White Classes B, C, or D Gestational hypertension Chronic hypertension Placenta previa (with or without bleeding) Other significant medical illness Other significant antepartum hemorrhage Obesity (BMI ≥ 35) Twin pregnancy Significant tobacco, alcohol, drug use Gestational diabetes (White Class A) Severe psychosocial issues Abnormal fetal growth (suspected intrauterine growth Family history genetic disease or congenital restriction or large for dates) anomalies PROM 32-36 weeks Other significant family history, esp. DVT/PE Preterm labour 32-36 weeks and recurrent pregnancy losses Rh or atypical blood group sensitization Prior pregnancy history of: Hydramnios or oligohydramnios Preterm labour < 36 weeks Fetal malposition (breech, transverse) at 36 weeks Stillbirth or neonatal death Postdates ≥ 41 weeks Intrauterine growth restriction Anemia not responding to Fe (Hb