Documentation: Prenatal #1 Appointment date * MM DD YYYY Appointment start * Hour Minute Second AM PM Appointment location * client's home provider's office audio/video telehealth - client home audio/video telehealth - client other audio telehealth - client home audio telehealth - client other community location or shared space other Client name * First Name Last Name Client email * Date of birth * MM DD YYYY Age * Estimated delivery date * MM DD YYYY Height * Pre-pregnancy weight (lbs) * Current weight (lbs) * Number of previous live births * Number of vaginal births * Number of cesarean births * Number of previous terminations * Number of previous miscarriages * Age at first period * Length of cycle (days) * Number of spotting days * Number of bleeding days * Have you experienced a miscarriage after 13 weeks gestation? * yes no declined Have you experienced a stillbirth? * yes no declined How would you describe your past pregnancies? * How would you describe your past childbirth experiences? * Is there any aspect of your past experiences that you would like to work to prevent? * What are your current pregnancy symptoms? * What remedies have you tried? * Pre-pregnancy, how many days per week did you exercise? * 0 0-1 1-2 2-3 3-4 4-5 5-6 6-7 Currently, how many days per week do you exercise? * 0 0-1 1-2 2-3 3-4 4-5 5-6 6-7 In the past 30 days, have you experienced or been diagnosed with any of the following? hypertension hypotension heart disease overweight/obesity protein in urine diabetes kidney dysfunction or disease liver dysfunction or disease yeast infection bacterial vaginosis urinary tract infection STD/STI cancer of the reproductive region cancer of the breast cancer - other depression psychosis OCD anxiety other chronic disease or condition In the past 3 years, have you experienced or been diagnosed with any condition? hypertension hypotension heart disease overweight/obesity protein in urine diabetes kidney dysfunction or disease liver dysfunction or disease yeast infection bacterial vaginosis urinary tract infection STD/STI cancer of the reproductive region cancer of the breast cancer - other depression anxiety OCD psychosis other chronic disease or condition Is there a family history of any genetic abnormalities or conditions? autism spectrum disorder down's syndrome congenital defect sickle cell carrier sickle cell disease anemia other autoimmune condition neural tube defect hemophilia muscular dystrophy cerebral palsy other chronic condition Prenatal Care Information Prenatal care provider or practice * Type of provider seen * OB/GYN CM CNM TM/DEM NP MD other Are you satisfied with your current prenatal care? * yes no decline What risk level has your provider deemed you as? * low moderate high unknown How do you feel about physical touch? * How do you envision your onset of labor? * scheduled spontaneous declined What type of delivery do you envision? * vaginal cesarean declined Are you planning for an unmedicated or medicated birth? * unmedicated medicated declined What kind of environment are you planning to give birth in? * home birth center hospital declined Address of delivery location * Address 1 Address 2 City State/Province Zip/Postal Code Country What other services or therapies have you utilized? chiropractic acupuncture massage therapy physical therapy pelvic floor therapy psychotherapy/counseling yoga personal fitness training reiki other General concerns * Recommendations * Resources * Appointment end * Hour Minute Second AM PM Signed (doula provider) * Your changes have been saved.
