Antenatal Record - Family Medicine Reference
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4Antenatal Record 1
Ontario
In conjunction
Medical
Ministry of Health
with the
Association
and Long-Term Care
Patient’s Last Name
Patient’s First Name
Address – number, street name
Apt/Suite/Unit
City/Town
Province
Postal Code
Partner’s Last Name
Partner’s First Name
Telephone - Home
Telephone - Work
Language
Partner’s Occupation
Partner’s Educational level
Age
Date of birth
Age
Occupation
Educational level
Ethnic or Racial backgrounds:
Mother / Father
YYYY/MM/DD
OHIP No.
Patient File No.
Marital status
Birth attendant
Newborn care
Family Physician
Allergies or Sensitivities (describe reaction details)
Medications/Herbals
Pregnancy Summary
Dating Method
LMP
Certain
Yes
No
EDB (by dates)
Final EDB
YYYY/MM/DD
Dates
Cycle q _____
Regular
Yes
No
T
US
Contraceptive type
Last used
1
YYYY/MM/DD
T
US
2
Gravida
Term
Premature
Abortuses
Living
ART (e.g. IVF)
Obstetrical History
No.
Year
Sex
Gest. age
Birth
Length of
Place
Type of
Comments regarding pregnancy and birth
M/F
(weeks)
weight
labour
of birth
delivery
Medical History and Physical Exam (provide details in comments)
Initial Laboratory Investigations
Current Pregnancy
Genetic History
Family History
Test
Result
Test
Result
1. Bleeding
Y / N
22. At risk population
Y / N
38. At risk population
Y / N
2. Nausea, vomiting
Y / N
(e.g.: Ashkenazi, consanguinity , CF,
(e.g.: DM, DVT/PE, PIH/HT,
Hb
HIV
sickle cell, Tay Sachs, thalassemia)
3. Smoking ___cig/day
Y / N
postpartum depression, thyroid)
Family history of:
4. Alcohol, street drugs
Y / N
MCV
Counseled and test declined
Y / N
Physical Examination
23. Developmental delay
5. Occup/Environ. risks
Y / N
ABO
Last Pap
Y / N
24. Congenital anomalies
6. Dietary restrictions
Y / N
Ht._______ Wt._______
Y / N
25. Chromosomal disorders
7. Calcium adequate
Y / N
Rh
YYYY/MM/DD
Y / N
26. Genetic disorders
8. Preconceptual folate
Y / N
BMI______ BP _______
Antibody Screen
GC/Chlamydia
Medical History
Infectious Disease
Rubella immune
Urine C&S
39. Thyroid
9. Hypertension
Y / N
27. Varicella susceptible
Y / N
N / Abn
40. Chest
10. Endocrine
Y / N
28. STDs / HSV / BV
Y / N
HBsAg
N / Abn
41. Breasts
11. Urinary tract
Y / N
29. Tuberculosis risk
Y / N
N / Abn
VDRL
42. Cardiovascular
12. Cardiac/Pulmonary
Y / N
30. Other
Y / N
N / Abn
43. Abdomen
Sickle Cell
13. Liver, hepatitis, Gl
Y / N
N / Abn
44. Varicosities / Extrm.
14. Gynaecology/ Breast
Y / N
N / Abn
Psychosocial
45. External genitalia
Prenatal Genetic Investigations
Result
15. Hem./Immunology
Y / N
31. Poor social support
Y / N
N / Abn
46. Cervix, vagina
32. Relationship problems
Y / N
16. Surgery
Y / N
N / Abn
a)
All ages-MSS, IPS, FTS
47. Uterus
33. Emotional/Depression
Y / N
17. Blood transfusion
Y / N
N / Abn
48. Size: ______ weeks
34. Substance abuse
Y / N
b)
Age
35 at EDB-CVS/amnio
18. Anaesthetic compl.
Y / N
49. Adnexae
19. Psychiatric
35. Family violence
Y / N
Y / N
N / Abn
c) If a or b declined, or twins, then MSAFP
50. Other
20. Epilepsy/ Neurological
Y / N
36. Parenting concerns
Y / N
N / Abn
21. Other
Y / N
37. Relig. / Cultural issues
Y / N
d) Counseled and test declined, or too late
Comments
Signature
Date
Signature
Date
4293-64 (05/03)
Canary – Mother’s chart – forward to hospital
Pink – Attendant’s copy
White – infant’s chart
7530-5624
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