CONFIDENTIAL INDIANA DEPARTMENT OF CORRECTION

PRENATAL RECORD
State Form 46336 (1-94)

MEDICAL HISTORY
LMP Quickening EDC

Check box if positive and describe findings

Nausea Fatigue Headache Urinary Leukorrhea Infections _____________

PRESENT

Vomiting Constipation Visual Dist. Edema Bleeding Accidents _____________

Current medication

Comments

Diabetes Hypertension Multiple Births Heart Disease Congenital Disease

FAMILY

Comments

Prior method of contraception Menarche Cycle Duration

HEENT Respiratory Neuropsych Allergies Hospitalization

PAST

Cardiovas G.I. G.U. Transfusions Operations Childhood Diseases

Comments

Prenatal classes Where?

Yes No

PREVIOUS PREGNANCY
Mo. Mo. of Duration Type Birth
No. Sex Anesth. Infant Complications Mother Complications
Yr. Gest. Of Labor of Del. Weight

PATIENT IDENTIFICATION
Full name

Number

Date of birth (mo., day, yr.)

Lock
 PHYSICAL EXAMINATION
Skin Breast Cardio Abdomen Height
Extremities Weight Non-pregnant weight

HEENT Neck Lungs Neurogical Nodes

Comments

External genitalia Vagina Cervix

Uterus Adnexa Rectum

Diagonal conjugate Pubic arch Bi-ischial

Spines Sacrum Type of pelvis

Blunt Sharp Adequate Inadequate Borderline

LABORATORY DATA
Serology Date (mo., day, yr.) Pap smear G.C. culture

Positive Negative
Rubella Titer Hgb Hct Blood type

SUBSEQUENT VISITS
Gest. Urine Fundus Position
Date Week B.P. Weight Edema FHR Return Comments
P/S Ht.

Risk condition

Signature of M.D. Date signed (month, day, year)