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PREVIOUS EDITION IS NOT USABLENSN 7540-00-634-4276MEDICAL RECORDDATEPRENATAL AND PREGNANCY07/01/2013PATIENT INFORMATIONLAST NAMEFIRST NAMENestorKathySTREET ADDRESSCITY333 East 3rd StreetMIDDLE INITIALJSTATEChicagoAREA CODEAREA CODENUMBER312555-5555ILID NUMBERTELEPHONE (Work)TELEPHONE (Home)NUMBERZIP CODE60635AGEDAY OF BIRTH (Month, Day, Year)EXT.13579RACEWHITEHISPANIC WHITEAMERICAN INDIAN/ALASKA NATIVEBLACKHISPANIC BLACKASIAN/PACIFIC ISLANDERMARRIEDDIVORCEDSEPARATEDHOMEMAKEROUTSIDE WORKTYPE OF WORK16WIDOWEDEMERGENCY CONTACTHUSBAND/FATHER OF BABYAREA CODETELEPHONENUMBER666-6666Louise Reddecker312AREA CODENUMBERNEWBORN'S PHYSICIANREFERRED BY312555-5555RobertsonNAMETELEPHONERobert NestorOCCUPATIONSTUDENTMARITAL STATUSSINGLE24EDUCATION (Last gradecompleted)FINAL ESTIMATED DELIVERY DATEHOSPITAL OF DELIVERYPRIMARY PROVIDER/GROUPMEDICAID NUMBER/INSURANCE10/27/2013Brookside Medical CenterBCBS333-55-8888ILNUMBER OF PREGNANCIESTOTALFULL TERM10PREMATURE ABORTIONS INDUCTED ABORTIONS SPONTANEOUS000ECTOPICSMULTIPLE BIRTHS00LIVING0PAST PREGNANCIES (LAST MTYPEDELIVERYANESTHESIAPLACE OFDELIVERYPRETERMLABORDELIVERYYES NOCOMMENTS/COMPLICATIONSMENSTRUAL HISTORYMENSESLAST MENSTRUAL PERIODDEFINITEAPPROXIMATE (MONTH KNOWN)UNKNOWNNORMAL OR (Date)YESQ (Days)28NOYESSYMPTOMS SINCE LAST MENSTRUAL PERIODDESCRIBE ALL SYMPTOMSMENARCHEON BCP ATCONCEPTNOAGE ONSEThCG (Date)11Nausea, Fatigue, BloatingRELATIONSHIP TO SPONSORSPONSOR'S NAMELASTDEPART./SERVICEFIRSTHOSPITAL OR MEDICAL FACILITYPATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.or SSN; Sex)MISPONSOR'S ID NUMBER(SSN or Other)RECORDS MAINTAINED ATREGISTER NO.WARD NO.PRENATAL AND PREGNANCYMedical RecordSTANDARD FORM 533 (REV. 12-1999)Prescribed by GSA/ICMR FMR (41 CFR) 101-11.203
NSN 7540-00-634-4276LAST NAMEFIRST RDERKIDNEY DISEASE/UTIPSYCHIATRIC0HISTORY OFABNORMAL PAP0UTERINE OMESTICVIOLENCEHISTORY OF BLOODTRANSFUSION0000RELEVANT FAMILYHISTORY000GYN SURGERY00OPERATIONS/HOSPITALIZATIONS(Year and Reason)00USE OF TOBACCOPRIOR TO PREGNANCY NOW00OTHER (Specify)0NUMBER OF CIGARETTESPER DAY0ANESTHETICCOMPLICATIONS0D (RH) SENSITIZEDDETAIL POSITIVE REMARKS(Include Date and Treatment)0INFERTILITY0135790BREAST0ID NUMBERO NEG POSALLERGIES (DRUGS)0HEART DISEASE0JPAST MEDICAL HISTORYDETAIL POSITIVE REMARKSITEM(Include Date and Treatment)PULMONARY(TB, ASTHMA)O NEG POSITEMMIDDLE INITIALUSE OF STREET DRUGSUSE OF ALCOHOLNO. OFYEARSSMOKEDNUMBER OF DRINKS PER DAY0PRIOR TOPREGNANCYNOW00NO. OF YEARSDRINKING0AMOUNT PER DAYPRIOR TOPREGNANCYNOW00NO. OF YEARS USE0COMMENTS/COUNSELINGGENETICS SCREENING/TERATOLOGY COUNSELING(Includes Patient, Baby's Father, or anyone in Either Family)ITEMPATIENT'S AGE IS GREATER THAN 35 YEARSTHALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR ASIANBACKGROUND (MCV IS LESS THAN 80)NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA, ORANENCEPHALY)CONGENITAL HEART DEFECTDOWN SYNDROMETAY-SACHS (E.G., JEWISH, CAJUN, FRENCH CANADIAN)SICKLE CELL DISEASE OR TRAIT (AFRICAN)HEMOPHILIAYES NOITEMYES NOMENTAL RETARDATION/AUTISMIF YES, WAS PERSON TESTED FOR FRAGILE XOTHER INHERITED GENETIC OR CHROMOSOMAL DISORDERMATERIAL METABOLIC DISORDER *E.G., INSULIN-DEPENDENTDIABETES, PKU)PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTSNOT LISTED ABOVEMUSCULAR DYSTROPHYMEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST MENSTRUALPERIODCYSTIC FIBROSISIF YES, LIST AGENT(S)HUNTINGTON CHOREARECURRENT PREGNANCY LOSS OR A STILLBIRTHANY OTHERCOMMENTS/COUNSELINGSTANDARD FORM 533 (REV. 12-1999) PAGE 2
NSN 7540-00-634-4276INFECTION HISTORYYES NOITEMITEMYES NOHIGH RISK HEPATITIS B/IMMUNIZEDRASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIODLIVE WITH SOMEONE WITH TBHISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILISEXPOSED TO TBOTHERPATIENT OR PARTNER HAS HISTORY OF GENITAL HERPESCOMMENTSDRUG ALLERGYRELIGIOUS/CULTURAL CONSIDERATIONSNoneBaptistANESTHESIA CONSULT PLANNEDYESNOINTERVIEWER'S SIGNATUREINITIAL PHYSICAL EXAMINATIONEXAM DATEPRE-PREGNANCY WEIGHTPRESENT WEIGHTHEIGHTBP02/24/2013135#140#5'4"110/70CHECK ETEETHCERVIXNORMALINFLAMMATIONLESIONSTHYROIDNO. OF WEEKS:UTERUS LYMPH NODESSUBPUBIC ARCHNORMALWIDENARROWRECTUMGYNECOID PELVIC TYPEYESNOCMCOMMENTS (List type and explain abnormality)MEDICATION LISTPLANSPROBLEMSTYPESTART DATEPNVsSTOP DATE02/24/2013ESTIMATED DELIVERY DATE (EDD)CONFIRMATIONACTIONLMPINITIAL 1303/19/20136910/21/201310/21/2013ORIG. DATE18-20 WEEK UPDATEWEEKSQUICKENINGFUNDAL HT. AT UMBIL.FHT W/FETOSCOPEULTRASOUNDPATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; IDNo. or SSN; Sex; Date of Birth; Rank/Grade)NEW DATEINITIAL EDD10/21/2013INITIALED BYMJHFINAL EDD10/21/2013INITIALED BYMJHREGISTER NO.WARD NO.STANDARD FORM 533 (REV. 12-1999) PAGE 3
NSN 7540-00-634-4276LAST NAMEFIRST NAMENestorKathyMIDDLE INITIAL ID NUMBERJ1357903/11/2013 MJH Fatigue, Nausea-110/72141Neg/Neg04/07/2013 MJH Scan Dates -112/68142Neg/Neg05/05/2013 MJH No c/o-03/19/20139 04/07/2013 12PROVIDER(Initials)Neg/Neg URINE(GLUCOSE/ALBUMIN)NEXTAPPOINTMENT (Date)1406PRESENT ABSENTWEIGHT110/7002/24/2013DATEEDEMACERVIX REFHRPRESENTATIONFUNDALHEIGHT (CM)WEEKS GEST.(BEST EST.)VISITSPRETERM LABORSIGNS/SYMPTOMSCOMMENTS05/05/2013 1615.00 -108/66144Neg/Neg06/03/2013 MJH No c/o06/03/2013 2019.00 110/72147Neg/Neg07/01/2013 MJH FM x 2 weeks106/60151Neg/Neg07/01/2013 24PROBLEMSMJH No c/oCOMMENTSSTANDARD FORM 533 (REV. 12-1999) PAGE 4
NSN 7540-00-634-4276LABORATORY AND EDUCATIONTYPEBLOOD TYPED (RH) TYPEPAP TESTINITIAL LABSHIV COUNSELING/TESTINGANTIBODY SCREENRUBELLAVDRLHCT/HGBURINE CULTURE/SCREENHB s CLINEDNEGATIVEMJH03/11/2013NegMJH03/11/20131.23 (Rubella IGG 335.812.703/11/2013Neg03/11/2013None DetectedHGB ELETROPHORESISOPTIONAL LABSMJHOTHERPOSITIVE03/11/2013COMMENTS/ADDITIONAL MJHTAY-SACHS8-18 WEEK LABS(When KERS03/19/201303/19/20131st TM Scan confirms EDC, FHB,Singleton FetusNeg for Trisomy 18, Trisomy 21,and Open Neural Tube DefectsMJHMJHAMNIO/CVSKARYOTYPEAMNIOTIC FLUID (AFP)46, XXOTHER46, XYNORMALABNORMALPATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.or SSN; Sex; Rank/Grade)REGISTER NO.WARD NO.STANDARD FORM 533 (REV. 12-1999) PAGE 5
NSN 7540-00-634-4276LAST NAMEFIRST NAMENestorKathyTYPE24-28 WEEK LABSJDATERESULTPERCENTAGEHCT/HGBDIABETES SCREENGTT (If screen abnormal)REVIEWED13579COMMENTS/ADDITIONAL LABG/DL1 HOURFBS1 HOUR2 HOUR3 HOURD (RH) ANTIBODY SCREEND IMMUNE GLOBULIN (RHG)GIVEN (28 WEEKS)HCT/HGB (Recommended)32-36 WEEK LABSMIDDLE INITIAL ID YDIAGROUP B STREP SCOUNSELEDNEWBORN CAR SEATANESTHESIA PLANSPOSTPARTUM BIRTH CONTROLTOXOPLASMOSISPRECAUTIONS (CATS/RAWMEAT)ENVIRONMENTAL/WORKHAZARDSCHILDBIRTH CLASSESTUBAL STERILIZATIONPHYSICAL/SEXUAL ACTIVITYVBAC COUNSELINGLABOR SIGNSCIRCUMCISIONNUTRITION COUNSELINGTRAVELBREAST OR BOTTLE FEEDINGLIFESTYLE, TOBACCO,ALCOHOLRESULTSTUBAL STERILIZATIONDATE CONSENT SIGNEDINITIALSCOMMENTS/COUNSELINGSTANDARD FORM 533 (REV. 12-1999) PAGE 6
NSN BUMIN)NEXTAPPOINTMENT (Date)WEIGHTABSENTBLOODPRESSUREEDEMAPRESENTCERVIX NDALHEIGHT (CM)DATEWEEKS GEST.(BEST EST.)SUPPLEMENTAL VISITSPRETERM LABORSIGNS/SYMPTOMSCOMMENTSPROGRESS NOTESPATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.or SSN; Sex; Rank/Grade)REGISTER NO.WARD NO.STANDARD FORM 533 (REV. 12-1999) PAGE 7
NSN 7540-00-634-4276LAST NAMEFIRST NAMENestorKathyMIDDLE INITIAL ID NUMBERJ13579PROGRESS NOTESSTANDARD FORM 533 (REV. 12-1999) PAGE 8
NSN 7540-00-634-4276DISCHARGE/POSTPARTUMDELIVERY INFORMATIONTYPE OF DELIVERYDELIVERY DATEVAGINALDELIVERY AT PSVBACFORPRIMARYREPEAT-FAILED VBACLOW TRANSVERSECLASSICALLOW VERTICALREPEAT - DURALGENERALINDUCEDNO LABORLOCAL/PUDENDALSPINALOTHERPOSTPARTUM HER:DISCHARGE DATEDISCHARGE NMALEYESBIRTH WEIGHTNONAME OF BABYCOMPLICATIONS/ANOMALIESHOME WITH MOTHERNEONATAL DEATHTRANSFEROTHERSTILLBIRTHIN HOSPITALMATERNALHB/HCT LEVELDIAGNOSTIC STUDIES PENDINGFEEDING METHODBREASTMEDICATIONSCONTRACEPTIVE METHOD (If applicable)BOTTLESECONDARY DIAGNOSIS/PREEXISTING CONDITIONSASTHMAOTHERFOLLOW-UP ATIONS GIVENREMARKSD (Rho)(D)) IMMUNE GLOBULINDIABETESOTHER:DATEINTERIM CONTACTSCOMMENTSIGNATURE OF PROVIDER (AS REQUIRED)PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No.or SSN; Sex; Rank/Grade)REGISTER NO.WARD NO.STANDARD FORM 533 (REV. 12-1999) PAGE 9
NSN 7540-00-634-4276LAST NAMEFIRST NAMENestorKathyMIDDLE INITIAL ID NUMBERJ13579POSTPARTUM VISITSDATEALLERGIESLAB STUDIES REQUESTEDHGB/HCTMEDICATIONS/CONTRACEPTIONLAST PAP SMEAR (Date)MEDICATIONS/CONTRACEPTION DISPENSEDYESNOFEEDING METHODINTERIM HISTORYCONTRACEPTIVE METHODINTERVAL CARE RECOMMENDATIONSFOR GENERAL HEALTH PROMOTIONFOR REPRODUCTIVE HEALTH PROMOTIONREFERRALSEXAMINED BYRETURN VISIT (Date)PHYSICAL EXAMBPWEIGHTPAP EXTERNAL ENTSSTANDARD FORM 533 (REV. 12-1999) PAGE 10
NSN 7540-00-634-4276COMMENTS (Continue on back if needed)PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. (SSN orother); hospital or medical facility)REGISTER NO.WARD NO.STANDARD FORM 533 (REV. 12-1999) PAGE 11
prenatal and pregnancy. date. patient information. last name. id number street address. first name middle initial. city state. zip code day of birth (month, day, year) age approximate (month known) normal amount/duration final: menses prior (date) frequency monthly. age onset yes. no on bcp
