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born to a ____ year-old G P ( ) mother via ___________;

___________-delivered, _________-assisted; Apgar score: _____, ______;


Maturity Testing: _____________, Birth weight: ___________ kg

Pregnancy known at _____ months. Ultrasound done at _____ months Maternal Illnesses
Prenatal checkup started at _____ Result:  Hypertension in Pregnancy
months via _________ x _____ visits  Gestational DM
 Cancer
Patient was given:  Bronchial asthma
 Ferrous sulfate Exposures:  Pulmonary Tuberculosis
 Calcium carbonate  Smoking  Thyroid disease
 Multivitamins  Alcoholic beverage drinking  URTI
 Tetanus toxoid  Illicit drug use  UTI
 _______________  Ionizing radiation  Fever prior delivery

( ) Diabetes Mellitus ( ) Pulmonary Tuberculosis


( ) Hypertension ( ) Lung disease
( ) Cancer ( ) Heart Disease
( ) Bleeding disorders ( ) Liver disease
( ) Seizure disorder ( ) Kidney Disease
( ) Febrile related seizure ( ) Thyroid Disease
( ) Bronchial asthma ( ) Metabolic disease

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