TABLE  OF  CONTENTS

 I.  INTRODUCTION

II.  AMBULATORY PRENATAL FLOW SHEET

0.

Gestational Age

 2.00

0.

Corrected Gestational Age

 2.00

0.

Weeks Pregnant

 2.00

0.

Date

 2.00

1.

Last Menstrual Period

 4.00

2.

Diagnosis of Pregnancy

 5.00

3.

Data Base

 7.00

 

 

 

4.

Lab

 8.00

4A.

Blood Type

 9.00

4B.

Rh Antibody

 10.00

4C.

Rubella Titer

 15.00

4D.

Pap Smear

 18.00

4E.

PPD (Intermediate Tuberculosis Skin Test)

 20.00

4F.

Gonorrhea:  Diagnosis and Treatment

 25.00

4G.

Syphilis

 28.00

4H.

Hematocrit/Hemoglobin

 34.00

 

Thrombocytopenia

 38.00

 

Inherited Bleeding Disorders:  von Willebrand's Disease & Hemophilia

 40.10

 

Disseminated Intravascular Coagulation (DIC)

 40.20

4I.

Alpha-fetoprotein (Serum)

 41.00

4J.

Hepatitis

 42.00

4K.

Group B-Beta Streptococcus

 43.00

4L.

Chlamydia

 49.00

4M.

Herpes

 50.00

 

 

 

5.

Patient Education

 51.00

 

 

 

6.

Screening History

 52.00

6A.

Any Problems

 53.00

6B.

Pain

 54.00

 

Appendicitis and Pregnancy

 56.00

 

Preterm (Premature) Labor

 58.00

 

Ectopic Pregnancy

 66.00

 

Peptic Ulcer Disease (PUD)

 72.00

 

Gastroesophageal Reflux (GERD)

 75.00

 

Gallbladder Disease

 78.00

 

Acute Pancreatitis

 82.00

 

Irritable Bowel Syndrome (IBS)

 83.10

 

Gastrointestinal Endoscopy During Pregnancy

 83.20

6C.

Vaginal Bleeding

 84.00

 

Abruptio Placentae

 90.00

 

Placenta Previa

 92.00

 

Vaginitis

 95.00

 

Clear Vaginal Discharge

 100.00

 

Rupture of Membranes Prior to the Onset of Labor

 102.00

6D.

Dysuria

 109.00

6E.

Swelling

 110.00

6F.

Nausea-Vomiting

 111.00

 

Hepatitis

 115.00

 

Intrahepatic Cholestasis of Pregnancy (ICP)

 124.10

6G.

Fetal Movement

 125.00

6H.

Vitamins Iron

 127.00

 

 

 

7.

Screening Physical

 130.00

7A.

Weight

 131.00

7B

Hypertensive Disorders of Pregnancy

 137.00

7C.

Urine Protein/Glucose

 153.00

7D.

Fundal Height and Fetal Growth Abnormalities

 154.00

7E.

Fetal Heart Tones-Doppler

 159.00

7F.

Fetal Heart Tones-Fetoscopy

 161.00

7G.

Position Station

 163.00

7H.

Edema

 165.00

 

 

 

8.

Urine Culture and Sensitivity - Urinary Tract Infections

 166.00

 

 

 

9.

Ultrasound (Sonography)

 172.00

 

 

 

10.

Gestational Diabetes Screening

 176.00

 

 

 

11.

Formal Testing for Fetal Surveillance:

 180.00

 

NST

 

 

CST

 

 

Biophysical Profile

 

 

 

 

12.

Amniocentesis

 182.00

12A.

Chorionic Villus Sampling - CVS

 184.00

 

 

 

13.

Hospitalizations, Records

 186.00

 

 

 

31.

Risk Factors

 187.00

 

 

 

32.

Problems

 189.00

 

 

 

33.

Intrapartum and Postpartum Factors

 190.00

33A.

Breast-feeding

 191.00

 

Beneficial Properties of Breast Milk

 195.00

33D.

Circumcision

 199.00

 

 

 

III.  PRENATAL DATA BASE QUESTIONNAIRE

Obstetrical History

 202.00

 

 

 

 

A0.

Age over 35

 203.00

A0.

Age under 17

 205.00

A1.

Grand Multiparity

 207.00

A1.

Small for Gestational Age (see section 7D Fundal Height and Fetal)

 

 

Growth Abnormalities

 154.00

A1.

Large for Gestational Age

 210.00

A2.

Preterm

 212.00

A2.

Postterm

 214.00

A2.

Induction of Labor

 215.10

A3.

Induced and Spontaneous Abortions

 216.00

A3.

Mifepristone (RU-486)

 218.10

A4.

Perinatal Death

 219.00

 

Perinatal Grieving

 220.00

A5.

Previous Cesarean Delivery

 224.00

A6.

Birth Defects

 228.00

A7.

Neonatal Complications

 229.00

A8.

Maternal Complications

 230.00

A9.

Unplanned Pregnancy

 231.00

A10.

Unhappy about Pregnancy

 232.00

 

Paternity Testing

 233.00

 

Abuse During Pregnancy

 235.00

A11.

Infertility

 245.00

A12.

Last Menstrual Period

 248.00

A13.

Menstrual Cycles

 249.00

A14.

Symptoms of Early Pregnancy

 250.00

A15.

Prior Use of Oral Contraceptives

 251.00

A16.

Prior Use of Other Contraceptives

252.00

A17.

Episiotomy

 253.00

 

 

 

B.

Present Medical Problems

 255.00

 

 

 

C.

Past Medical History and Family History

 256.00

C1.

Cardiac Disease in Pregnancy

 257.00

 

Hyperlipidemia

 260.10

 

Prophylaxis Bacterial Endocarditis

 261.00

 

Cardiac Medications and Treatments

 264.00

 

Mitral Valve Prolapse

 267.00

 

Prosthetic Valves

 269.00

 

Cardiac Arrhythmias

 271.00

 

Peripartum Cardiomyopathy

 274.00

C2.

High Blood Pressure (moved to Section 7B Hypertensive Disorders)

 

C3.

Glucose Intolerance:  Gestational Diabetes Mellitus (GDM)

 278.00

 

Glucose Intolerance:  Gestational Diabetes Mellitus (DM) Type I and II

 281.00

 

Diabetic Ketoacidosis

 286.00

C4.

Pulmonary Disease

 

 

Tuberculosis

 289.00

 

Asthma

 293.00

 

Pneumonia

 299.00

C5.

Sexually Transmitted Diseases

 

C5(1)

Herpes Simplex

 301.00

C5(2)

Condyloma Acuminata

 307.00

C5(3)

Chlamydia

 309.00

C6.

Psychiatric Problems

 313.00

C7.

Alcoholism

 319.00

C8.

Kidney Disease

 320.00

 

Kidney Stones in Pregnancy

 323.00

C9.

Cancer

 327.00

C10.

Seizures (Convulsions) and Other Neurological Problems

 330.00

 

Headaches

 338.00

 

Multiple Sclerosis (MS)

 342.00

 

Spinal Cord Injury

 344.00

 

Facial Nerve Palsy (Bell's et al.)

 345.10

 

Idiopathic Intracranial Hypertension

 345.20

C11.

Twins (Multiple Gestation)

 346.00

C12.

Birth Defects/Inherited Diseases

 354.00

 

First Trimester Screening for Down Syndrome & Trisomy 18

 355.10

 

Maternal Serum Screening

 356.00

 

Cystic Fibrosis (CF)

 359.00

C13.

Allergies

 363.00

 

Latex Allergy

 364.10

C14.

Ears, Nose, Throat, Eyes

 

 

Hearing Loss in Infancy

 365.00

 

Ears, Nose, Throat

 367.00

 

Common Ophthalmologic Problems

 370.00

 

Glaucoma

 372.00

C14(1)

Dental Disease

 373.10

C15.

Uterine-Cervical Abnormality

 374.00

C16.

Hyperthyroidism

 375.00

 

Hypothyroidism

 379.00

 

Postpartum Thyroiditis

 381.10

C17-19.

Ethnic, Geographic, Religious Risk Factors

 382.00

C18.

Infectious Disease Section

 

 

Antibacterials

 383.00

 

Antiparasitic Drugs

 387.00

 

Antifungal Drugs

 389.00

 

Varicella/Chickenpox

 390.00

 

Infectious Mononucleosis/EB Virus Infection

 395.00

 

Rocky Mountain Spotted Fever

 415.30

 

Anthrax

 415.40

 

Smallpox

 415.50

C20.

Other

 416.00

 

 

 

D.

Surgeries and Hospitalizations

 417.00

 

 

 

E.

Health Maintenance

 418.00

 

Influenza Vaccine

 421.00

 

 

 

F.

Medications

 423.00

 

Analgesics

 424.00

 

 

 

G.

Allergies

 426.00

 

 

 

H.

Patient Profile

 427.00

 

Others in Home

 427.00

 

Occupation

 427.00

 

Exposures

 427.00

 

Education

 427.00

 

Special Diet

 427.00

 

Caffeine

 429.10

 

Constipation

 429.50

 

Exercise

 430.00

 

Travel

 435.00

 

Smoking

 439.00

 

Alcohol

 441.00

 

Drug Abuse

 443.00

 

Marijuana

 446.00

 

Opiates

 449.00

 

Cocaine

 452.00

 

PCP, LSD, Amphetamines

 457.00

 

 

 

I.

Review of Systems

 459.00

 

 

 

J.

Physical Exam

 463.00

 

 

 

K.

Human Immunodeficiency Virus (HIV) and

 

 

Acquired Immunodeficiency Syndrome (AIDS) in Pregnancy

 467.00

 

Guidelines for Health Care Workers Exposed to HIV/AIDS/HCV

 478.00

 

 

 

L.

Occupational Medicine and Toxicology

 

 

Women in the Workplace

 490.00

 

Exposures that affect reproduction

 493.00

 

Lead Toxicity

496.10

 

Radiation Exposure

 497.00

 

Magnetic Resonance Imaging

 500.00

 

Breast Feeding and Maternal Drug or Chemical Exposure

 501.00

 

Electromagnetic Radiation

 510.00

 

 

 

M.

Trauma in Pregnancy

 

 

Physiologic Changes & Pregnancy

 511.00

 

Trauma

 513.00

 

Intubation & Airway

 523.00

 

Neuromuscular Blockade

 526.00

 

Seat Belts in Pregnancy

 528.00

 

Living Wills for Pregnant Women

 529.00

 

Toxicology

 

 

Acute Poisoning in Pregnancy

 530.00

 

Acetaminophen Toxicity in Pregnancy

 535.00

 

Iron Overdose

 539.00

 

Burns

 542.00

 

Carbon Monoxide

 547.00

 

Venomous Bites

 549.00

 

 

 

N.

Thromboembolic Disease and Pregnancy

 552.00

 

 

 

O.

Ethnic, Geographic, Religious Risk Factors

 559.00

 

Jehovah's Witnesses

 560.00

 

Sickle Cell Anemia

 562.00

 

 

 

P.

Orthopedics

 

 

Low Back Pain

 566.00

 

Fractures, Sprains, Strains

 570.00

 

Carpal Tunnel Syndrome

 572.00

 

Foot Problems

 573.10

 

 

 

Q.

Genetic Questionnaire

 574.00

 

 

 

R.

Anesthesia

 

 

Vaginal Labor and Delivery

 579.00

 

Cesarean Delivery

 583.00

 

 

 

S.

Dermatology

 

 

Common Dermatologic Problems

 586.00

 

Less Common Dermatologic Problems

 588.00

 

Scabies

 593.10

 

 

 

T.

Postpartum Complications

 

 

Mastitis

 594.00

 

Postpartum Endometritis

 596.00

 

Postpartum Sexual Dysfunction

 600.00

 

 

 

U.

Endocrine Disease

 

 

Sheehan's Syndrome

 601.00

 

Upd IV,9,05