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Betty Richmond Female 27 years (05/02/1987) Alias: Bets

PP: (416) 568-3569

Visit time remaining: 20 min

Reason for Visit:
First time mother prenatal intake

Comments:
There may be religious concerns regarding care

Partner's Information

Partner's Last Name:

Partner's First Name:

Partner's Age:

years old

Partner's Occupation:

Partner's Educational Level:

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Partner's Phone:

Partner's Ethic or Racial Background:

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Completed some high school
High school graduate
Completed some college
Associate degree
Bachelor's degree
Completed some postgraduate
Master's degree
Ph.D., law or medical degree
Other advanced degree beyond a Master's degree

Delivery Information

Birth Attendant:

Newborn Care:

Family Physician:

Allergies

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	SEVERE ActivePenicillinIntolerance Reaction: Itching, redness, and or dryness of the skin Life Stage: Adult Onset Date:Jun. 23, 2012 Last updated by Irma Sumac at 15:12:12 on Jan. 12, 2012

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Allergy Intolerance

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Onset Date:

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Menstrual History

First day of last menstrual period:

Certain

Period Frequency:

Regular (monthly)

Irregular

Period Duration:

Short

Normal

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Birth Control Used:

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Birth control last used on:

Birth control used during conception:

Yes No

Estimated Date of Birth

EDB (by dates):

(Calculated from LMP)

Final Estimated Date of Birth

Dating Method:

Dates

First Trimester Ultrasound

Second Trimester Ultrasound

Assisted Reproductive Technologies

Final EDB:

Obstetrical History

Total Pregnancies:

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Premature:

Abortion (Induced):

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Ectopics:

Multiple Births:

Living:

Past Pregnancies (Details and Outcomes)

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Date:

Place of Delivery:

Length of Labour:

Preterm Labour:

Yes

Anesthesia:

Yes

Gestation Age:

Delivery Type:

Sex:

Birth Weight:

Comments:

Date:

Place of Delivery:

Length of Labour:

Preterm Labour:

Yes

Anesthesia:

Yes

Gestation Age:

Delivery Type:

Sex:

Birth Weight:

Comment:

Medical History

No positive findings No positives on remaining

Family History

No positive findings No positives on remaining

Antenatal 1 Comments

Comments:

Initial Investigations

Laboratory Investigations

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Haemoglobin:

MCV:

Blood Type:

Rh:

Antibody Screen:

Rubella Immune:

HBsAg:

VDRL:

Sickle Cell:

HIV:

Counselled and declined

Last Pap:

Performed On:

GC:

Chlamydia:

Urine C&S:

Additional Laboratory Tests

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Prenatal Genetic Investigations

Counselled and patient declined

Too late for testing

Maternal Serum Screening:

Quad Screening:

First Trimester Screening:

Integrated Prenatal Screening:

Serum Integrated Prenatal Screening:

Recommended Immunoprophylaxis

Patient is Rh-negative:

Yes

Patient is susceptible to rubella:

Yes

Required Newborn Immunizations

Hepatitis B Immunoglobulin (HB-IG):

Yes

Hepatitis B Vaccine:

Yes

Antenatal Exam

Date:

Urine Protein:

Weight:

lbs

45.36 kg

Blood Pressure:

sitting

right arm

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using

adult cuff

Blood Pressure:

sitting

right arm

using

adult cuff

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Gestational Age:

weeks

days

SFH:

Presentation:

Position:

Fetal Heart Rate:

Fetal Movement:

Comments:

Ultrasound

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Date of Test:

Gestational Age:

weeks

days

Results:

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Haemoglobin:

Blood Type:

Rh:

Repeat Antibody Screen:

1 hr. GCT:

2 hr. GTT:

GBS:

Additional Laboratory Tests

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Test Name:

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Would you like to import relevant information for Kenneth Keys, the patient's partner during the last pregnancy?

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Patient's Last Name Mahoney			Patient's First Name Sarah
Address - number, street name 123 Memory Lane						Apt/Suite/Unit
City/Town Richmond Hill				Province ON		Postal Code L4E 5B4
Telephone - Home (416) 212-8232	Telephone - Work			Language English
Date of Birth 1981/02/12	Age 32	Occupation Implementation Specialist			Educational Level Bachelor's
OHIP No. 2311-394-204-WJ		Patient File No. 31988			Marital Status Married

Partner's Last Name Keys		Partner's First Name Kenneth
Partner's Occupation Data Services Manager	Partner's Educational Level Postgraduate		Age 33
Ethnic or Racial Backgrounds: Mother / Father Caucasian / Caucasian

LMP 2014/03/10	Certain	Yes No
Cycle q Normal	Regular	Yes No
Contraceptive Type Male condom	Last used	2014/03/20

No.	Year	Sex M/F	Gest. age (weeks)	Birth weight	Length of labour	Place of birth	Type of delivery	Comments regarding pregnancy and birth
1	2012	F	40	3kg	4hrs	MSH	Vaginal

Current Pregnancy
1.	Bleeding	Y / N
2.	Nausea, vomiting	Y / N
3.	Smoking 3 ______cig/day	Y / N
4.	Alcohol, street drugs	Y / N
5.	Occup/Environ. risks	Y / N
6.	Dietary restrictions	Y / N
7.	Calcium adequate	Y / N
8.	Preconceptual folate	Y / N

Birth Attendant Lisa Strait	Newborn Care Lisa Strait	Family Physician Dr. Joseph Feelgood

Medical History
9.	Hypertension	Y / N
10.	Endocrine	Y / N
11.	Urinary tract	Y / N
12.	Cardiac/Pulmonary	Y / N
13.	Liver, hepatitis, GI	Y / N
14.	Gynaecology/Breast	Y / N
15.	Hem./Immunology	Y / N
16.	Surgery	Y / N
17.	Blood transfusion	Y / N
18.	Anaesthetic compl.	Y / N
19.	Psychaitric	Y / N
20.	Epilepsy/Neurological	Y / N
21.	Other	Y / N

Genetic History
22.	At risk population (e.g. Ashkenazi, consanguinity, CF, sickle cell, Tay Sachs, thalassemia)	Y / N
Family history of:
23.	Developmental delay	Y / N
24.	Congenital anomalies	Y / N
25.	Chromosomal disorders	Y / N
26.	Genetic disorders	Y / N

Infectious Disease
27.	Varicella susceptible	Y / N
28.	STDs / HSV / BV	Y / N
29.	Tuberculosis risk	Y / N
30.	Other	Y / N

Psychosocial
31.	Poor social support	Y / N
32.	Relationship problems	Y / N
33.	Emotional/Depression	Y / N
34.	Substance abuse	Y / N
35.	Family violence	Y / N
36.	Parenting concerns	Y / N
34.	Relig./Cultural Issues	Y / N

Family History
38.	At risk population (e.g.: DM, DVT/PE, PIH/HT, postpartum depression, thyroid)	Y / N

Physical Examination
Ht.	5'4" _________	Wt.	100lbs _________
BMI	17.16 _________	BP	145/95 _________

39.	Thyroid	N/Abn
40.	Chest	N/Abn
41.	Breasts	N/Abn
42.	Cardiovascular	N/Abn
43.	Abdomen	N/Abn
44.	Varicosities / Extrm.	N/Abn
45.	External genitalia	N/Abn
46.	Cervix, vagina	N/Abn
47.	Uterus	N/Abn
48.	Size:____weeks
49.	Adnexae	N/Abn
50.	Other	N/Abn

Test		Result	Test	Result
Hb			HIV
MCV			Counseled and test declined
ABO			Last Pap
Rh			YYYY/MM/DD
Antibody Screen			GC/Chlamydia
Rubella immune			Urine C&S
HBsAg
VDRL
Sickle Cell
Prenatal Genetic Investigations				Result
a)	All ages-MSS, IPS, FTS
b)	Age ≥ 35 at EDB-CVS/amino
c)	If a or b declined, or twins, then MSAFP
d)	Counseled and test declined, or too late

						Antenatal Record 2
Patient's Last Name Mahoney					Patient's First Name Sarah
Birth Attendant Lisa Strait					Newborn Care Lisa Strait
Family Physician Dr. Joseph Feelgood					Final EDB	Allergies or Sensitivities Severe Penicillin Allergy (Reaction: Itching, redness, and or dryness of the skin)	Medications / Herbals Symbicort 200 Turbuhaler (200µG, 6µG, Powder, Inhalation)
G 1	T 1	P 0	A 0	L 1

Identified Risk Factors	Plan of Management
Smoking	Planning to quit cold turkey
Hypertension	Monitor and patient will stay active

Date	GA (weeks)	Weight	B.P.	Urine Prot.	SFH	Pres. Posn.	FHR/ FM	Comments
30/04/2014	9	103lbs	145/90	30+	5cm	??	??
28/05/2014	13	107lbs	140/90	Negative	7cm?	??	??

Date	GA	Result

Hb
ABO/Rh
Repeat ABS
1 hr. GCT
2 hr. GTT
GBS