Click on a section to enter information
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Patient's Last Name
Mahoney
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Patient's First Name
Sarah
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Address - number, street name
123 Memory Lane
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Apt/Suite/Unit | |||||
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City/Town
Richmond Hill
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Province
ON
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Postal Code
L4E 5B4
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Telephone - Home
(416) 212-8232
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Telephone - Work |
Language
English
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Date of Birth
1981/02/12
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Age
32
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Occupation
Implementation Specialist
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Educational Level
Bachelor's
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OHIP No.
2311-394-204-WJ
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Patient File No.
31988
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Marital Status
Married
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Antenatal Record 1
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Partner's Last Name
Keys
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Partner's First Name
Kenneth
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Partner's Occupation
Data Services Manager
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Partner's Educational Level
Postgraduate
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Age
33
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Ethnic or Racial Backgrounds: Mother / Father
Caucasian / Caucasian
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Birth Attendant
Lisa Strait
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Newborn Care
Lisa Strait
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Family Physician
Dr. Joseph Feelgood
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Allergies or Sensitivities (describe reaction details)
Severe Penicillin Allergy (Reaction: Itching, redness, and or dryness of the skin)
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Medications/Herbals
Medications/Herbals
Symbicort 200 Turbuhaler (200µG, 6µG, Powder, Inhalation)
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Pregnancy Summary
| LMP 2014/03/10 | Certain |
Yes
No
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| Cycle q Normal | Regular |
Yes
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| Contraceptive Type Male condom | Last used | 2014/03/20 |
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EDB (by dates)
12/15/2014
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Final EDB |
Dating Method
Dates
T1US
T2US
ART (e.g. IVF)
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Gravida
1
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Term
1
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Premature
0
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Abortuses
0
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Living
1
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Obstetrical History
| 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 |
Medical History and Physical Exam
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Current Pregnancy
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1.
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Bleeding
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Y
/
N
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2.
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Nausea, vomiting
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Y
/
N
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3.
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Smoking
3 ______cig/day
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Y
/
N
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4.
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Alcohol, street drugs
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Y
/
N
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5.
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Occup/Environ. risks
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Y
/
N
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6.
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Dietary restrictions
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Y
/
N
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7.
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Calcium adequate
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Y
/
N
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8.
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Preconceptual folate
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Y
/
N
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Medical History
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9.
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Hypertension
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Y
/
N
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10.
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Endocrine
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Y
/
N
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11.
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Urinary tract
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Y
/
N
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12.
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Cardiac/Pulmonary
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Y
/
N
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13.
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Liver, hepatitis, GI
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Y
/
N
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14.
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Gynaecology/Breast
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Y
/
N
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15.
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Hem./Immunology
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Y
/
N
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16.
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Surgery
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Y
/
N
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17.
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Blood transfusion
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Y
/
N
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18.
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Anaesthetic compl.
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Y
/
N
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19.
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Psychaitric
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Y
/
N
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20.
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Epilepsy/Neurological
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Y
/
N
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21.
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Other
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Y
/
N
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Genetic History
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22.
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At risk population
(e.g. Ashkenazi, consanguinity, CF, sickle cell, Tay Sachs, thalassemia)
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Y
/
N
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Family history of:
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23.
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Developmental delay
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Y
/
N
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24.
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Congenital anomalies
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Y
/
N
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25.
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Chromosomal disorders
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Y
/
N
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26.
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Genetic disorders
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Y
/
N
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Infectious Disease
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27.
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Varicella susceptible
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Y
/
N
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28.
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STDs / HSV / BV
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Y
/
N
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29.
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Tuberculosis risk
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Y
/
N
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30.
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Other
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Y
/
N
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Psychosocial
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31.
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Poor social support
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Y
/
N
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32.
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Relationship problems
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Y
/
N
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33.
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Emotional/Depression
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Y
/
N
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34.
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Substance abuse
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Y
/
N
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35.
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Family violence
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Y
/
N
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36.
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Parenting concerns
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Y
/
N
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34.
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Relig./Cultural Issues
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Y
/
N
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Family History
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38.
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At risk population
(e.g.: DM, DVT/PE, PIH/HT, postpartum depression, thyroid)
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Y
/
N
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Physical Examination
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Ht.
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5'4" _________ |
Wt.
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100lbs _________ |
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BMI
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17.16 _________ |
BP
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145/95 _________ |
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39.
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Thyroid
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N/Abn
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40.
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Chest
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N/Abn
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41.
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Breasts
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N/Abn
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42.
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Cardiovascular
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N/Abn
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43.
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Abdomen
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N/Abn
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44.
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Varicosities / Extrm.
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N/Abn
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45.
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External genitalia
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N/Abn
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46.
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Cervix, vagina
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N/Abn
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47.
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Uterus
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N/Abn
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48.
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Size:____weeks
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49.
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Adnexae
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N/Abn
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50.
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Other
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N/Abn
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Comments
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3. Pt also smokes cigars 1/week
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Initial Laboratory Investigations
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Test
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Result
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Test
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Result
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Hb
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HIV
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MCV
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Counseled and test declined
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ABO
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Last Pap
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Rh
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YYYY/MM/DD | ||
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Antibody Screen
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GC/Chlamydia
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Rubella immune
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Urine C&S
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HBsAg
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VDRL
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Sickle Cell
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Prenatal Genetic Investigations
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Result
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a)
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All ages-MSS, IPS, FTS
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b)
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Age ≥ 35 at EDB-CVS/amino
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c)
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If a or b declined, or twins, then MSAFP
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d)
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Counseled and test declined, or too late
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Click on a section to enter information
|
|
Antenatal Record 2
|
||||||
|
Patient's Last Name
Mahoney
|
Patient's First Name
Sarah
|
||||||
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Birth Attendant
Lisa Strait
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Newborn Care
Lisa Strait
|
||||||
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Family Physician
Dr. Joseph Feelgood
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Final EDB
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Allergies or Sensitivities
Severe Penicillin Allergy (Reaction: Itching, redness, and or dryness of the skin)
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Medications / Herbals
Symbicort 200 Turbuhaler (200µG, 6µG, Powder, Inhalation)
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G
1
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T
1
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P
0
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A
0
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L
1
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Identified Risk Factors
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Plan of Management
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Smoking
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Planning to quit cold turkey
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Hypertension
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Monitor and patient will stay active
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Recommended Immunoprophylaxis
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Rh Neg.
Rh IG Given:
YYYY/MM/DD
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Rubella booster postpartum | Newborn needs: |
Hep B IG
Hep B vaccine
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Subsequent Visits
| Date |
GA (weeks) |
Weight | B.P. |
Urine Prot. |
SFH |
Pres. Posn. |
FHR/ FM |
Comments |
Ultrasound
| Date | GA | Result |
Additional Lab Investigations
| Hb | |
| ABO/Rh | |
| Repeat ABS | |
| 1 hr. GCT | |
| 2 hr. GTT | |
| GBS | |
Discussion Topics
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Exercise
Work plan
Intercourse
Travel
Prenatal classes
Birth plans
On call provider
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Preterm labour
PROM
APH
Fetal movement
Admission timing
Pain management
Labour support
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Breastfeeding
Circumcision
Discharge planning
Car seat safety
Depression
Contraception
Postpartum care
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