PG. 1 BLANK TEMPLATE DO NOT FILL WITH PATIENT INFO – Patient name: Age yo Gx Px Labs: TO DO: Problem List: [ ] Give welcome packet MRN: HIV: [ ] Prenatal intake RN DOB: Date of dx, CD4, VL [ ] APR registry: fax registration Confirmed and med form to enroll new ART history Gest age by L=week patient CD4 nadir US on x/x/x [ ] ANTC at 32 weeks for HIV+ HIV genotype [ ] 36 week post-partum HLAB5701 anticipatory guidance visit OI, hospitalization hx Final EDD: x/x/x by US on date POBH: POSTPARTUM: Prenatal labs: LMP: (sure/unsure) LMP EDD: Social hx (partner, kids, living situation): Dating sono on date: GA Allergies: xwxd, sono EDD x/x/x. Doula Discussion: Delivery Plan: Final EDD: x/x/x by xw US on HPP referral: date Contraceptive Method: Meds: 1st BAPAC visit: study number, Research protocols: Most recent visit: eligible/ineligible, date enrolled, date next study Next visit: visit Patient contact info: Primary care provider: Sonos: 00/00/17: Dating sono EGA, whether c/w menstrual – Pharmacy: dating 1-415- phone Anatomy scan EGA, placental location, 00/00/17: – 1-415- fax presentation, EFW w/ percentile, any anomalies, other pertinent info Genetics: Peds follow-up: 1st trim screening 11+2-14+2 weeks. NT result, – serum results Italicize past meds 2nd trim screening 15+0-20+0 weeks. Serum results – Amnio - Vaccines:
PG. 1 BLANK TEMPLATE – DO NOT FILL WITH PATIENT INFO Patient name: MRN: DOB: Gest age by L=week US on x/x/x Final EDD: x/x/x by US on date LMP: (sure/unsure) LMP EDD: Dating sono on date: GA xwxd, sono EDD x/x/x. Final EDD: x/x/x by xw 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: [ ] Give welcome packet [ ] Prenatal intake RN [ ] APR registry: fax registration and med form to enroll new patient [ ] ANTC at 32 weeks for HIV+ [ ] 36 week post-partum anticipatory guidance visit POSTPARTUM: Allergies: Doula Discussion: HPP referral: Meds: Italicize past meds Sonos: 00/00/17: Dating sono – EGA, whether c/w menstrual dating 00/00/17: 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:
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