Prenatal Weight Gain Charts
ADVERTISEMENT
1
2
3
4N.C. Department of Health and Human Services
1. Last Name
First Name
MI
Women’s and Children’s Health Section
2. Patient Number
PRENATAL WEIGHT GAIN CHART
3. Date of Birth
(MM/DD/YYYY)
Month
Day
Year
Pre-Pregnancy Underweight
□
□
4. Race
American Indian or Alaska Native
Asian
□
□
BMI <18.5
Black/African American
Native Hawaiian/Other Pacific Islander
□
□
Unknown
White
□
□
Weight Gain Recommendations (singleton):
5. Ethnic Origin
Hispanic Cuban
Hispanic Mexican American
□
□
Hispanic Other
Hispanic Puerto Rican
♦ 2.2–6.6 lb. gain 1
trimester
st
□
□
Not Hispanic/Latino
Unreported
♦ 1 lb. gain per week 2
and 3
trimesters
nd
rd
□
□
6. Gender
Female
Male
♦ 28–40 lb. total weight gain
7. County of Residence
45
EDC ______________________________
Ht. (without shoes) __________________
Pre-Pregnancy Wt. ___________________
Pre-Pregnancy BMI __________________
40
Weeks
Date
Gestation
Weight
Notes
35
30
25
20
15
10
5
baseline
-5
0
4
8
12
16
20
24
28
32
36
40
Weeks of Gestation
DHHS 2388 (Revised 06/10)
Women’s and Children’s Health Section (Review 06/13)
Source: Institute of Medicine, 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC. National Academies Press; Committee to Reexamine IOM Pregnancy Guidelines.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical