Pregnancy Testing Encounter Record
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1PREGNANCY TESTING ENCOUNTER RECORD
Name
Age
Date of Birth
Allergies
Current Method of Contraception
Current Medications (prescription, OTC, vitamins, herbal)
Last Normal Menstrual Period (LNMP)
Last bleeding episode, if not LNMP
Reason for requesting pregnancy test
Positive urine pregnancy test:
EDC (by LMP) __________
(check all that apply)
Verification form given
Options counseling
Multivitamin with folic acid recommended
Prenatal education
Prenatal care recommended
Refer for supportive services (WIC, MCHP, Healthy Start, DSS)
Negative urine pregnancy test:
(check all that apply)
Repeat pregnancy test recommended if no menses in 2 weeks
Preconception counseling
Family planning appointment given Date ________ Time _______
Contraception education
Emergency contraception
□ offered
□ given
Condoms
□ offered
□ given
Quick Start contraception initiated (name) ___________________________
Multivitamin with folic acid recommended
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I understand that the pregnancy test is not always 100% accurate and that actual
diagnosis of pregnancy or other condition depends on a clinical evaluation which should
be performed in 2 weeks. I assume full responsibility for any decisions I make. I have
been offered non-directive options counseling and state without reservation that I have
not been influenced or advised by any member of the Health Department staff to accept
any one particular option.
Date
Client Signature
Interpreter Signature
CHN Signature
DHMH/FHA/CMCH – MARLYLAND STATE FAMILY PLANNING PROGRAM CLINICAL GUIDELINES
PREGNANCY TESTING ENCOUNTER FORM (DHMH 4648) – REVISED 10/21/09
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