TABLE OF CONTENTS
I. INTRODUCTION |
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II. AMBULATORY PRENATAL FLOW SHEET
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0. |
2.00 |
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0. |
Corrected Gestational Age |
2.00 |
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0. |
Weeks Pregnant |
2.00 |
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0. |
2.00 |
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1. |
4.00 |
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2. |
5.00 |
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3. |
7.00 |
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4. |
8.00 |
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4A. |
9.00 |
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4B. |
Rh Antibody |
10.00 |
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4C. |
15.00 |
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4D. |
18.00 |
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4E. |
PPD (Intermediate Tuberculosis Skin Test) |
20.00 |
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4F. |
Gonorrhea: Diagnosis and Treatment |
25.00 |
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4G. |
Syphilis |
28.00 |
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4H. |
Hematocrit/Hemoglobin |
34.00 |
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Thrombocytopenia |
38.00 |
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Inherited Bleeding Disorders: von Willebrand's Disease & Hemophilia |
40.10 |
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Disseminated Intravascular Coagulation (DIC) |
40.20 |
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4I. |
Alpha-fetoprotein (Serum) |
41.00 |
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4J. |
Hepatitis |
42.00 |
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4K. |
Group B-Beta Streptococcus |
43.00 |
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4L. |
49.00 |
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4M. |
Herpes |
50.00 |
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5. |
Patient Education |
51.00 |
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6. |
Screening History |
52.00 |
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6A. |
Any Problems |
53.00 |
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6B. |
Pain |
54.00 |
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Appendicitis and Pregnancy |
56.00 |
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Preterm (Premature) Labor |
58.00 |
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Ectopic Pregnancy |
66.00 |
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Peptic Ulcer Disease (PUD) |
72.00 |
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Gastroesophageal Reflux (GERD) |
75.00 |
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Gallbladder Disease |
78.00 |
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Acute Pancreatitis |
82.00 |
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Irritable Bowel Syndrome (IBS) |
83.10 |
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Gastrointestinal Endoscopy During Pregnancy |
83.20 |
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6C. |
Vaginal Bleeding |
84.00 |
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Abruptio Placentae |
90.00 |
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Placenta Previa |
92.00 |
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Vaginitis |
95.00 |
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Clear Vaginal Discharge |
100.00 |
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Rupture of Membranes Prior to the Onset of Labor |
102.00 |
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6D. |
Dysuria |
109.00 |
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6E. |
Swelling |
110.00 |
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6F. |
Nausea-Vomiting |
111.00 |
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Hepatitis |
115.00 |
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Intrahepatic Cholestasis of Pregnancy (ICP) |
124.10 |
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6G. |
Fetal Movement |
125.00 |
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6H. |
Vitamins Iron |
127.00 |
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7. |
Screening Physical |
130.00 |
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7A. |
Weight |
131.00 |
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7B |
Hypertensive Disorders of Pregnancy |
137.00 |
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7C. |
Urine Protein/Glucose |
153.00 |
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7D. |
Fundal Height and Fetal Growth Abnormalities |
154.00 |
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7E. |
Fetal Heart Tones-Doppler |
159.00 |
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7F. |
Fetal Heart Tones-Fetoscopy |
161.00 |
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7G. |
Position Station |
163.00 |
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7H. |
Edema |
165.00 |
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8. |
Urine Culture and Sensitivity - Urinary Tract Infections |
166.00 |
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9. |
Ultrasound (Sonography) |
172.00 |
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10. |
Gestational Diabetes Screening |
176.00 |
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11. |
Formal Testing for Fetal Surveillance: |
180.00 |
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NST |
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CST |
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Biophysical Profile |
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12. |
Amniocentesis |
182.00 |
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12A. |
Chorionic Villus Sampling - CVS |
184.00 |
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13. |
Hospitalizations, Records |
186.00 |
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31. |
Risk Factors |
187.00 |
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32. |
Problems |
189.00 |
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33. |
Intrapartum and Postpartum Factors |
190.00 |
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33A. |
Breast-feeding |
191.00 |
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Beneficial Properties of Breast Milk |
195.00 |
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33D. |
Circumcision |
199.00 |
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III. PRENATAL DATA BASE
QUESTIONNAIRE
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Obstetrical History |
202.00 |
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A0. |
Age over 35 |
203.00 |
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A0. |
Age under 17 |
205.00 |
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A1. |
Grand Multiparity |
207.00 |
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A1. |
Small for Gestational Age (see section 7D Fundal Height and Fetal) |
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Growth Abnormalities |
154.00 |
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A1. |
Large for Gestational Age |
210.00 |
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A2. |
Preterm |
212.00 |
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A2. |
Postterm |
214.00 |
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A2. |
Induction of Labor |
215.10 |
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A3. |
Induced and Spontaneous Abortions |
216.00 |
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A3. |
Mifepristone (RU-486) |
218.10 |
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A4. |
Perinatal Death |
219.00 |
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Perinatal Grieving |
220.00 |
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A5. |
Previous Cesarean Delivery |
224.00 |
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A6. |
Birth Defects |
228.00 |
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A7. |
Neonatal Complications |
229.00 |
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A8. |
Maternal Complications |
230.00 |
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A9. |
Unplanned Pregnancy |
231.00 |
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A10. |
Unhappy about Pregnancy |
232.00 |
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Paternity Testing |
233.00 |
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Abuse During Pregnancy |
235.00 |
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A11. |
Infertility |
245.00 |
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A12. |
Last Menstrual Period |
248.00 |
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A13. |
Menstrual Cycles |
249.00 |
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A14. |
Symptoms of Early Pregnancy |
250.00 |
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A15. |
Prior Use of Oral Contraceptives |
251.00 |
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A16. |
Prior Use of Other Contraceptives |
252.00 |
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A17. |
Episiotomy |
253.00 |
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B. |
Present Medical Problems |
255.00 |
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C. |
Past Medical History and Family History |
256.00 |
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C1. |
Cardiac Disease in Pregnancy |
257.00 |
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Hyperlipidemia |
260.10 |
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Prophylaxis Bacterial Endocarditis |
261.00 |
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Cardiac Medications and Treatments |
264.00 |
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Mitral Valve Prolapse |
267.00 |
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Prosthetic Valves |
269.00 |
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Cardiac Arrhythmias |
271.00 |
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Peripartum Cardiomyopathy |
274.00 |
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C2. |
High Blood Pressure (moved to Section 7B Hypertensive Disorders) |
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C3. |
Glucose Intolerance: Gestational Diabetes Mellitus (GDM) |
278.00 |
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Glucose Intolerance: Gestational Diabetes Mellitus (DM) Type I and II |
281.00 |
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Diabetic Ketoacidosis |
286.00 |
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C4. |
Pulmonary Disease |
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Tuberculosis |
289.00 |
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Asthma |
293.00 |
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Pneumonia |
299.00 |
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C5. |
Sexually Transmitted Diseases |
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C5(1) |
Herpes Simplex |
301.00 |
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C5(2) |
Condyloma Acuminata |
307.00 |
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C5(3) |
Chlamydia |
309.00 |
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C6. |
Psychiatric Problems |
313.00 |
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C7. |
Alcoholism |
319.00 |
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C8. |
Kidney Disease |
320.00 |
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Kidney Stones in Pregnancy |
323.00 |
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C9. |
Cancer |
327.00 |
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C10. |
Seizures (Convulsions) and Other Neurological Problems |
330.00 |
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Headaches |
338.00 |
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Multiple Sclerosis (MS) |
342.00 |
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Spinal Cord Injury |
344.00 |
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Facial Nerve Palsy (Bell's et al.) |
345.10 |
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Idiopathic Intracranial Hypertension |
345.20 |
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C11. |
Twins (Multiple Gestation) |
346.00 |
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C12. |
Birth Defects/Inherited Diseases |
354.00 |
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First Trimester Screening for Down Syndrome & Trisomy 18 |
355.10 |
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Maternal Serum Screening |
356.00 |
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Cystic Fibrosis (CF) |
359.00 |
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C13. |
Allergies |
363.00 |
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Latex Allergy |
364.10 |
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C14. |
Ears, Nose, Throat, Eyes |
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Hearing Loss in Infancy |
365.00 |
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Ears, Nose, Throat |
367.00 |
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Common Ophthalmologic Problems |
370.00 |
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Glaucoma |
372.00 |
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C14(1) |
Dental Disease |
373.10 |
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C15. |
Uterine-Cervical Abnormality |
374.00 |
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C16. |
Hyperthyroidism |
375.00 |
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Hypothyroidism |
379.00 |
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Postpartum Thyroiditis |
381.10 |
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C17-19. |
Ethnic, Geographic, Religious Risk Factors |
382.00 |
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C18. |
Infectious Disease Section |
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Antibacterials |
383.00 |
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Antiparasitic Drugs |
387.00 |
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Antifungal Drugs |
389.00 |
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Varicella/Chickenpox |
390.00 |
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Infectious Mononucleosis/EB Virus Infection |
395.00 |
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Rocky Mountain Spotted Fever |
415.30 |
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Anthrax |
415.40 |
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Smallpox |
415.50 |
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C20. |
Other |
416.00 |
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D. |
Surgeries and Hospitalizations |
417.00 |
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E. |
Health Maintenance |
418.00 |
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Influenza Vaccine |
421.00 |
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F. |
Medications |
423.00 |
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Analgesics |
424.00 |
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G. |
Allergies |
426.00 |
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H. |
Patient Profile |
427.00 |
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Others in Home |
427.00 |
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Occupation |
427.00 |
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Exposures |
427.00 |
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Education |
427.00 |
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Special Diet |
427.00 |
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Caffeine |
429.10 |
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Constipation |
429.50 |
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Exercise |
430.00 |
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Travel |
435.00 |
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Smoking |
439.00 |
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Alcohol |
441.00 |
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Drug Abuse |
443.00 |
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Marijuana |
446.00 |
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Opiates |
449.00 |
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Cocaine |
452.00 |
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PCP, LSD, Amphetamines |
457.00 |
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I. |
Review of Systems |
459.00 |
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J. |
Physical Exam |
463.00 |
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K. |
Human Immunodeficiency Virus (HIV) and |
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Acquired Immunodeficiency Syndrome (AIDS) in Pregnancy |
467.00 |
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Guidelines for Health Care Workers Exposed to HIV/AIDS/HCV |
478.00 |
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L. |
Occupational Medicine and Toxicology |
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Women in the Workplace |
490.00 |
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Exposures that affect reproduction |
493.00 |
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Lead Toxicity |
496.10 |
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Radiation Exposure |
497.00 |
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Magnetic Resonance Imaging |
500.00 |
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Breast Feeding and Maternal Drug or Chemical Exposure |
501.00 |
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Electromagnetic Radiation |
510.00 |
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M. |
Trauma in Pregnancy |
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Physiologic Changes & Pregnancy |
511.00 |
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Trauma |
513.00 |
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Intubation & Airway |
523.00 |
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Neuromuscular Blockade |
526.00 |
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Seat Belts in Pregnancy |
528.00 |
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Living Wills for Pregnant Women |
529.00 |
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Toxicology |
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Acute Poisoning in Pregnancy |
530.00 |
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Acetaminophen Toxicity in Pregnancy |
535.00 |
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Iron Overdose |
539.00 |
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Burns |
542.00 |
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Carbon Monoxide |
547.00 |
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Venomous Bites |
549.00 |
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N. |
Thromboembolic Disease and Pregnancy |
552.00 |
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O. |
Ethnic, Geographic, Religious Risk Factors |
559.00 |
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Jehovah's Witnesses |
560.00 |
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Sickle Cell Anemia |
562.00 |
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P. |
Orthopedics |
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Low Back Pain |
566.00 |
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Fractures, Sprains, Strains |
570.00 |
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Carpal Tunnel Syndrome |
572.00 |
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Foot Problems |
573.10 |
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Q. |
Genetic Questionnaire |
574.00 |
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R. |
Anesthesia |
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Vaginal Labor and Delivery |
579.00 |
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Cesarean Delivery |
583.00 |
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S. |
Dermatology |
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Common Dermatologic Problems |
586.00 |
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Less Common Dermatologic Problems |
588.00 |
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Scabies |
593.10 |
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T. |
Postpartum Complications |
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Mastitis |
594.00 |
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Postpartum Endometritis |
596.00 |
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Postpartum Sexual Dysfunction |
600.00 |
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U. |
Endocrine Disease |
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Sheehan's Syndrome |
601.00 |
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