Name/Age:

EGA:
PNC:
H/o:

G?P?:
EDD:
EFW:
P/w:

LMP:

Name/Age:
EGA:
PNC:
H/o:

HPI:

HPI:

Pregnancy probs:

Pregnancy probs:

FM:
HA:
Epidural?

VB:
Vision:
Contraception?

LOF:
RUQ pain: Dysuria:

CTX:

ABO/Rh:
GC/CT:
Quad:
OBHx:
Year

Ab:
Rubella:
1hGTT:
GA

GBS:
HbsAg:
3hGTT:
VD/CS

HIV:
UCx:

N/V:
d/c:

RPR:
UA:

Complications

GynHx: Menarche:
reg:
#d:
PAPs:
PMH: DM, anemia, CA, thyroid
PSH:
Meds: PNV
Allergies:
FH: DM, HTN, MI, stroke, thyroid, sz, Gyn CA, coagulopathies, genetic dz
SH: tobacco/EtOH/drugs, domestic violence
BP:
PR:
RR:
Temp:
Gen:
Cardiac:
Resp:
Abd:
Extr/DTRs:
Membranes:
FHTs: Base:
Var:
Accels:
Decels:
Cat:
Toco:
US: Placenta:
Previa:
Position:
AFI:
BPP:
Labs:
BGs:
UA:

STD hx:

SpO2:

Pre-E labs:

G?P?:
EDD:
EFW:
P/w:

LMP:

FM:
HA:
Epidural?

VB:
Vision:
Contraception?

LOF:
RUQ pain: Dysuria:

CTX:

ABO/Rh:
GC/CT:
Quad:
OBHx:
Year

Ab:
Rubella:
1hGTT:
GA

GBS:
HbsAg:
3hGTT:
VD/CS

HIV:
UCx:

Assessment:

Problem List/Plan:

Problem List/Plan:

RPR:
UA:

Complications

GynHx: Menarche:
reg:
#d:
PAPs:
PMH: DM, anemia, CA, thyroid
PSH:
Meds: PNV
Allergies:
FH: DM, HTN, MI, stroke, thyroid, sz, Gyn CA, coagulopathies, genetic dz
SH: tobacco/EtOH/drugs, domestic violence
BP:
PR:
RR:
Temp:
Gen:
Cardiac:
Resp:
Abd:
Extr/DTRs:
Membranes:
FHTs: Base:
Var:
Accels:
Decels:
Cat:
Toco:
US: Placenta:
Previa:
Position:
AFI:
BPP:
Labs:
BGs:
UA:

Assessment:

N/V:
d/c:

STD hx:

SpO2:

Pre-E labs: