PG. 1 BLANK TEMPLATE – DO NOT FILL WITH PATIENT INFO Patient name: Age yo Gx Px Labs: TO DO: Problem List: MRN: HIV: DOB: Date of dx, CD4, VL Confirmed ART history Gest age by CD4 nadir L=week US on HIV genotype Allergies: x/x/x HLAB5701 Doula Discussion: OI, hospitalization hx LMP: Prenatal labs: POBH: Final EDD: x/x/x by US Meds: on date Social hx (partner, kids, living situation): 1st BAPAC visit: Most recent visit: Delivery Plan: Next visit: Contraceptive Method: Patient contact info: Research protocols: study number, eligible/ineligible, date enrolled, date next study visit Primary care provider: Pharmacy: 1-415- phone 1-415- fax Sonos: 00/00/15: Dating sono – EGA, whether c/w menstrual dating 00/00/15: Anatomy scan – EGA, placental location, presentation, EFW w/ percentile, any anomalies, other pertinent info Peds follow-up: Genetics: 1st trim screening – 11+2-14+2 weeks. NT result, serum results 2nd trim screening – 15+0-20+0 weeks. Serum results Amnio - Vaccines: Italicize past meds
PG. 1 BLANK TEMPLATE – DO NOT FILL WITH PATIENT INFO Patient name: MRN: DOB: Gest age by L=week US on x/x/x LMP: Final EDD: x/x/x by US on date 1st BAPAC visit: Most recent visit: Next visit: Patient contact info: Primary care provider: Pharmacy: 1-415- phone 1-415- fax Peds follow-up: Age yo Gx Px Problem List: HIV: Date of dx, CD4, VL Confirmed ART history CD4 nadir HIV genotype HLAB5701 OI, hospitalization hx POBH: Social hx (partner, kids, living situation): Delivery Plan: Contraceptive Method: Research protocols: study number, eligible/ineligible, date enrolled, date next study visit Labs: Prenatal labs: TO DO: Allergies: Doula Discussion: Meds: Italicize past meds Sonos: 00/00/15: Dating sono – EGA, whether c/w menstrual dating 00/00/15: Anatomy scan – EGA, placental location, presentation, EFW w/ percentile, any anomalies, other pertinent info Genetics: 1st trim screening – 11+2-14+2 weeks. NT result, serum results 2nd trim screening – 15+0-20+0 weeks. Serum results Amnio - Vaccines:
HIVEXAntepartum-Care-Template-2016.01.28.docx