Prenatal Care Record Form printable pdf download

GREENVILLE MIDWIFERY CARE

NAME: ___________________________________________________

PRENATAL CARE RECORD (Page 1 of 2)

MR#: ____________________________________________________

Your age:

Race:

Phone (primary): ___________________________ Other: __________________________

Your DOB:

Country of birth:

Email:

Religious practices / cultural or ethnic considerations:

Highest level of education:

Name of partner / father of baby (FOB):

Occupation:

Relationship status: ☐Married to father of baby

☐Living with father of baby in a long‐term committed relationship

☐Single, father of baby not involved

Primary care provider / Phone:

☐Single, father of baby involved, supportive

☐Divorced ☐Widowed ☐Other: _____________________________________________

Dentist / Phone:

FOB’s age:

Race:

Occupation:

Phone (primary):

Phone (other):

Name of other emergency contact: __________________________

Ages, names, and health status of FOB’s other children (if applicable):

Phone: _________________________________________________

Relationship: ____________________________________________

Briefly tell us your reasons for choosing our practice and how you

Please list the ages and names of all members in your household:

found out about us.

MENSTRUAL HISTORY:

day of last menstrual period ______________________

How often do you have periods? Every __________ days

Was this a normal, regular, on‐time, normal period for you? ☐Yes ☐ No ______________________________________

Were you using any methods to prevent pregnancy? ☐No ☐Yes _____________________________________________

Did you conceive using infertility treatment? ☐No ☐Yes __________________________________________________

Date of 1

positive pregnancy test ____________________

Any spotting or bleeding since LMP? __________________

HISTORY SINCE LMP:

Since your last menstrual period, have you been exposed to any of the following:

☐ X‐Rays or exposure to hazardous chemicals or other substances _______________________________________________________

☐Rash or viral illnesses ☐Hospitalizations or emergency room visits _____________________________________________________

☐Travel outside the country? _____________________________________________________________________________________

☐Have you experienced any major life changes / stressors (moving, death in family, loss of job, etc) ____________________________

______________________________________________________________________________________________________________

Amt / Day prior to

Amt / day

# Years Use

Attempts to

List any medications (prescription or over‐the‐counter),

pregnancy

now

quit?

supplements, herbal preparations since LMP.

Tobacco use

Alcohol consumption

llicit (“street”) drugs

Prenatal Care Record Form

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