For Copies contact: RCP of NS, rcp@nshealth.ca Tel: 902-470-6798 Original-Mother/Hospital Record/Copy-Office Clinical Record

OBSTETRICAL HISTORY Gravida Para Abort SB NND Date Place Gest Mode of Del Complications/Comments Birth Wt Sex Health

dd/mm/yyyydd/mm/yyyydd/mm/yyyydd/mm/yyyy

DEMOGRAPHICS Patient̓ s name: Maiden name: Address: DOB: Age: HC#: Contact telephone #: Marital status: Highest level of education completed: Language: English French Arabic Other: Employed: N Y Type of work: Partnerʼs Name: Age: Race/ethnicity: Québécois Acadian Jewish Hispanic

African Canadian Caucasian First Nations Middle Eastern Mediterranean Other:

Race/ethnicity: Québécois Acadian Jewish Hispanic African Canadian Caucasian First Nations Middle Eastern Mediterranean Other:

Prenatal care provider(s): (Physician/Midwife/NP):

Language: English French Arabic Other:

Baby̓s Physician (in home community): Employed: No Yes Type of work:

PREGNANCY DATING EDD (Best Estimate) Regular cycles: N Y

OCP stopped: dd/mm/yyyy +ve preg test: dd/mm/yyyy Quickening dd/mm/yyyyLMP Date: dd/mm/yyyy

EDD: dd/mm/yyyy Conception (if known) Date: dd/mm/yyyy :DDEComments: dd/mm/yyyy

Ultrasound Date: dd/mm/yyyy :DDEsyadskeew dd/mm/yyyy Ultrasound Date: dd/mm/yyyy :DDEsyadskeew dd/mm/yyyy 18-21 wk U/S Date: dd/mm/yyyy :DDEsyadskeew dd/mm/yyyy

PRESENT PREGNANCY N Y Comments PAST ILLNESS N Y Comments Pre-Pregnancy Medications N Y N Y

Pre-conceptual folic acid N Y N Y

Depression/anxiety N Y N Y

Bleeding N Y N Y

Received immune globulin N Y N Y

Infections (e.g. UTI,STI) N Y N Y

Nausea /vomiting N Y N Y

Smoking: pre-preg (#/day) N Y N Y

now (#/day) N Y N Y

wishing to quit N Y N Y

Alcohol use N Y N Y

Substance use N Y N Y

Threatened preterm labour N Y N Y

N Y N Y

ALLERGIES : Drug NKDA Y Latex N Y

Blood transfusion acceptable N Y Anesthesia consult N Y

NOVA SCOTIA PRENATAL RECORD 1ReproductiveCare Programof Nova Scotia

OperationsAnaes problemsBlood/productsRespiratoryRenal diseaseDiabetesCardiacGynecologicThromboembolismHypertensionCNS disorder/migraineMental healthSubstance useSTIOther

Revised Oct./2013

Sure N Y Cycle length:

dd/mm/yyyydd/mm/yyyy

Current Medications