Q (Days) hCG + (Date)
NSN 7540-00-634-4276PREVIOUS EDITION IS NOT USABLE
MEDICAL RECORD PRENATAL AND PREGNANCYDATE
PATIENT INFORMATIONLAST 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:
MENSESPRIOR (Date)
FREQUENCYAGE ONSETMONTHLY
YES
NO
ON BCP AT CONCEPT
YES NO
MENARCHE
OUTSIDE WORK
FULL TERM PREMATURE ABORTIONS INDUCTED ABORTIONS SPONTANEOUS ECTOPICS MULTIPLE BIRTHS LIVINGTOTAL
PAST PREGNANCIES (LAST SIX)
DATE (MO/YR)
GA WEEKS
LENGTH OF
LABOR
BIRTH WEIGHT
SEX TYPE DELIVERY ANESTHESIA PLACE OF
DELIVERY
PRETERM LABOR
DELIVERYYES NOF M
MENSTRUAL HISTORYLAST MENSTRUAL PERIOD
DEFINITE
UNKNOWN
TELEPHONEAREA CODE NUMBER
FINAL ESTIMATED DELIVERY DATE
WHITE
BLACK
HISPANIC WHITE
HISPANIC BLACK
AMERICAN INDIAN/ALASKA NATIVE
ASIAN/PACIFIC ISLANDER
DESCRIBE ALL SYMPTOMSSYMPTOMS SINCE LAST MENSTRUAL PERIOD
MARITAL STATUS
WIDOWEDSINGLE
DIVORCED
MARRIED
SEPARATED
OCCUPATION
TYPE OF WORK
EDUCATION (Last grade completed)
HOMEMAKER
STUDENT
COMMENTS/ COMPLICATIONS
RACE
EMERGENCY CONTACT
REFERRED BY
MEDICAID NUMBER/INSURANCE
TELEPHONE (Home)AREA CODE NUMBER
TELEPHONEAREA CODE NUMBER
NEWBORN'S PHYSICIAN
HOSPITAL OF DELIVERY
NUMBER OF PREGNANCIES
REGISTER NO. WARD NO.
DEPART./SERVICE
RELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
SPONSOR'S NAMEFIRST MI
SPONSOR'S ID NUMBER (SSN or Other)
HOSPITAL OR MEDICAL FACILITY
TELEPHONE (Work)AREA CODE NUMBER EXT.
PRIMARY PROVIDER/GROUP
HUSBAND/FATHER OF BABYNAME
LAST
STANDARD FORM 533 (REV. 12-1999) Prescribed by GSA/ICMR FMR (41 CFR) 101-11.203
PRENATAL AND PREGNANCY Medical Record
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex)
NSN 7540-00-634-4276
USE OF TOBACCONUMBER OF CIGARETTES
PER DAY
PRIOR TO PREGNANCY NOW
NO. OF YEARS SMOKED
USE OF ALCOHOLNUMBER OF DRINKS PER DAY
PRIOR TO PREGNANCY
NOW
NO. OF YEARS DRINKING
STANDARD FORM 533 (REV. 12-1999) PAGE 2
PAST MEDICAL HISTORY
ITEM O NEG + POS
DETAIL POSITIVE REMARKS (Include Date and Treatment) ITEM O NEG
+ POSDETAIL POSITIVE REMARKS (Include Date and Treatment)
DIABETES
HYPERTENSION
HEART DISEASE
AUTOIMMUNE DISORDER
KIDNEY DISEASE/UTI
PSYCHIATRIC
NEUROLOGIC/ EPILEPSYHEPATITIS/LIVER DISEASEVARICOSITIES/ PHLEBITISTHYROID DYSFUNCTIONTRAUMA/DOMESTIC VIOLENCEHISTORY OF BLOOD TRANSFUSION
D (RH) SENSITIZED
PULMONARY (TB, ASTHMA)
ALLERGIES (DRUGS)
BREAST
HISTORY OF ABNORMAL PAPUTERINE ANOMALY/ DES
INFERTILITY
RELEVANT FAMILY HISTORY
USE OF STREET DRUGS
COMMENTS/COUNSELING
AMOUNT PER DAYPRIOR TO PREGNANCY
NOW
NO. OF YEARS USE
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
OPERATIONS/HOS- PITALIZATIONS (Year and Reason)
GYN SURGERY
OTHER (Specify)
ANESTHETIC COMPLICATIONS
GENETICS SCREENING/TERATOLOGY COUNSELING (Includes Patient, Baby's Father, or anyone in Either Family)
ITEM ITEMPATIENT'S AGE IS GREATER THAN 35 YEARS
CONGENITAL HEART DEFECTDOWN SYNDROME
TAY-SACHS (E.G., JEWISH, CAJUN, FRENCH CANADIAN)
SICKLE CELL DISEASE OR TRAIT (AFRICAN)
HEMOPHILIA
MUSCULAR DYSTROPHYCYSTIC FIBROSIS
HUNTINGTON CHOREARECURRENT PREGNANCY LOSS OR A STILLBIRTH
IF YES, WAS PERSON TESTED FOR FRAGILE X
OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER
MATERIAL METABOLIC DISORDER *E.G., INSULIN-DEPENDENT DIABETES, PKU)
PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE
MEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST MENSTRUAL PERIOD
IF YES, LIST AGENT(S)
ANY OTHERCOMMENTS/COUNSELING
THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR ASIAN BACKGROUND (MCV IS LESS THAN 80)
MENTAL RETARDATION/AUTISM
NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA, OR ANENCEPHALY)
YES NO YES NO
OTHER
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; IDNo. or SSN; Sex; Date of Birth; Rank/Grade)
WARD NO.REGISTER NO.
STANDARD FORM 533 (REV. 12-1999) PAGE 3
INFECTION HISTORYITEM ITEM
HIGH RISK HEPATITIS B/IMMUNIZEDLIVE WITH SOMEONE WITH TB
EXPOSED TO TB
PATIENT OR PARTNER HAS HISTORY OF GENITAL HERPES
SACRUM
SUBPUBIC ARCH
GYNECOID PELVIC TYPE
DRUG ALLERGY RELIGIOUS/CULTURAL CONSIDERATIONS
RESULT
ANESTHESIA CONSULT PLANNED
YES NO
PROBLEMSMEDICATION LIST
TYPE START DATE STOP DATEPLANS
ESTIMATED DELIVERY DATE (EDD)CONFIRMATION
ACTION DATE WEEKS EDD
LMPINITIAL EXAM
ULTRASOUND
QUICKENINGFUNDAL HT. AT UMBIL.FHT W/FETOSCOPEULTRASOUND
INITIALED BY
18-20 WEEK UPDATEACTION ORIG. DATE WEEKS NEW DATE FINAL EDD
INITIALED BY
INITIAL EDD
PRESENT WEIGHT
RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIODHISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS
YES NOYES NO
COMMENTS
INTERVIEWER'S SIGNATURE
COMMENTS (List type and explain abnormality)
INITIAL PHYSICAL EXAMINATIONPRE-PREGNANCY WEIGHT HEIGHT BPEXAM DATE
HEART
ABDOMEN
EXTREMITIES
SKIN
LYMPH NODES
RECTUM
ITEM
HEENT
FUNDI
TEETH
THYROID
BREASTS
LUNGS
ABNORMALNORMAL
CHECK ONEITEM
VULVA
VAGINA
CERVIX
NORMAL
NORMAL
NORMAL
NORMAL
AVERAGE
CONCAVE
NORMAL
YES
CONDYLOMA
LESIONS
FIBROIDS
BLUNT
ANTERIOR
NARROW
CM
NO. OF WEEKS:
DISCHARGE
LESIONS
INFLAMMATION
INFLAMMATION
MASS
NO
PROMINENT
STRAIGHT
WIDE
NO
REACHED
UTERUS SIZE
ADNEXA
DIAGONAL CONJUGATE
SPINES
NSN 7540-00-634-4276
PROBLEMS COMMENTS
VISITS
DATE
PRETERM LABOR SIGNS/SYMPTOMS
PRESENT ABSENT
WE
EK
S G
ES
T.
(BE
ST
ES
T.)
FUN
DA
L H
EIG
HT
(CM
)
PR
ES
EN
TATI
ON
FHR
FETA
L M
OV
EM
EN
T
CE
RV
IX E
XA
M
(DIL
./EFF
./ S
TA.)
ED
EM
A
PR
OV
IDE
R
(Initi
als)
WE
IGH
T
NE
XT
AP
PO
INT-
M
EN
T (D
ate)
COMMENTSBLOOD PRES- SURE
URINE (GLUCOSE/ ALBUMIN)
STANDARD FORM 533 (REV. 12-1999) PAGE 4
NSN 7540-00-634-4276
ID NUMBERMIDDLE INITIALFIRST NAMELAST NAME
LABORATORY AND EDUCATION
BLOOD TYPE
D (RH) TYPE
PAP TEST
HIV COUNSELING/TESTING
ANTIBODY SCREEN
RUBELLA
VDRL
HCT/HGB
URINE CULTURE/SCREEN
HB s AG
ULTRASOUND
MSAFP/MULTIPLE MARKERS
AMNIO/CVS
KARYOTYPE
AMNIOTIC FLUID (AFP)
NORMALABNORMAL
POSITIVE
NEGATIVEDECLINED
HGB ELETROPHORESIS
PPD
CHLAMYDIA
GC
TAY-SACHS
OTHER
SSAS AC
AF TA2
AA
SC
46, XX
46, XY
OTHER
PERCENTAGE G/DL
OTHER
NORMAL ABNORMAL
TYPE DATE
INIT
IAL
LAB
SO
PTI
ON
AL
LAB
S8-
18 W
EE
K L
AB
S
(Whe
n in
dica
ted/
elec
ted)
RESULT REVIEWED COMMENTS/ADDITIONAL LAB
A
AB
B
O
WARD NO.REGISTER NO.PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)
NSN 7540-00-634-4276
STANDARD FORM 533 (REV. 12-1999) PAGE 5
COMMENTS/COUNSELING
TYPE DATE RESULT REVIEWED COMMENTS/ADDITIONAL LAB
HCT/HGB
DIABETES SCREEN
GTT (If screen abnormal)
D (RH) ANTIBODY SCREEN
D IMMUNE GLOBULIN (RHG) GIVEN (28 WEEKS)
HCT/HGB (Recommended)
ULTRASOUND
VDRL
GC
CHLAMYDIA
GROUP B STREP (35-37 WEEKS)
COUNSELED
LIFESTYLE, TOBACCO, ALCOHOL
TRAVEL
CIRCUMCISION
VBAC COUNSELING
TUBAL STERILIZATION
POSTPARTUM BIRTH CONTROL
ENVIRONMENTAL/WORK HAZARDS
NEWBORN CAR SEAT
ANESTHESIA PLANS
TOXOPLASMOSIS PRECAUTIONS (CATS/RAW MEAT)
CHILDBIRTH CLASSES
PHYSICAL/SEXUAL ACTIVITY
LABOR SIGNS
NUTRITION COUNSELING
BREAST OR BOTTLE FEEDING
PERCENTAGE G/DL
1 HOUR
SIGNATURE
PERCENTAGE G/DL
FBS
2 HOUR
1 HOUR
3 HOUR
TYPE COMMENTS COMMENTSTYPEPLANS/EDUCATION
RESULTS TUBAL STERILIZATIONDATE CONSENT SIGNED INITIALS
NSN 7540-00-634-4276
ID NUMBERMIDDLE INITIALFIRST NAMELAST NAME
24-2
8 W
EE
K L
AB
S32
-36
WE
EK
LA
BS
STANDARD FORM 533 (REV. 12-1999) PAGE 6
PROGRESS NOTES
SUPPLEMENTAL VISITS
DATE
PRETERM LABOR SIGNS/SYMPTOMS
PRESENT ABSENT
WE
EK
S G
ES
T.
(BE
ST
ES
T.)
FUN
DA
L H
EIG
HT
(CM
)
PR
ES
EN
TATI
ON
FHR
FETA
L M
OV
EM
EN
T
CE
RV
IX E
XA
M
(DIL
./EFF
./ S
TA.)
ED
EM
A
PR
OV
IDE
R
(Initi
als)
WE
IGH
T
NE
XT
AP
PO
INT-
M
EN
T (D
ate)
COMMENTSBLOOD PRES- SURE
URINE (GLUCOSE/ ALBUMIN)
NSN 7540-00-634-4276
STANDARD FORM 533 (REV. 12-1999) PAGE 7
WARD NO.REGISTER NO.PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)
NSN 7540-00-634-4276
ID NUMBERMIDDLE INITIALFIRST NAMELAST NAME
PROGRESS NOTES
STANDARD FORM 533 (REV. 12-1999) PAGE 8
CESAREANVAGINAL
DISCHARGE/POSTPARTUM
DELIVERY INFORMATIONDELIVERY DATE
DELIVERY AT (Weeks)
TYPE OF DELIVERY
STILLBIRTHIN HOSPITAL
NEONATAL DEATHOTHER
COMPLICATIONS/ANOMALIES
SIGNATURE OF PROVIDER (AS REQUIRED)
LABORAUGMENTED
NO LABOR
SPONTANEOUS
INDUCED
ANESTHESIAGENERAL
OTHER
NONE
LOCAL/PUDENDAL
EPIDURAL
SPINAL
INTERIM CONTACTSDATE COMMENT
SVD
VACUUM
FORCEPS
EPISIOTOMY
LACERATIONS
VBAC
PRIMARYFOR
POSTPARTUM COMPLICATIONSNONE HEMORRHAGE INFECTION HYPERTENSION OTHER:
DISCHARGE INFORMATIONDISCHARGE DATE
MATERNALHB/HCT LEVEL
FEEDING METHOD
BREAST BOTTLE
CONTRACEPTIVE METHOD (If applicable) MEDICATIONS
DIAGNOSTIC STUDIES PENDING
SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS
ASTHMA
DIABETES
HYPERTENSION
OTHER
FOLLOW-UP APPOINTMENT
DATE LOCATION
REMARKSIMMUNIZATIONS GIVEN
D (Rho)(D)) IMMUNE GLOBULIN
DIABETES
OTHER:
NEONATALSEX
FEMALE
MALE
CIRCUMCISION
YES NOBIRTH WEIGHT NAME OF BABY
CLASSICAL REPEAT - ELECTIVE
REPEAT-FAILED VBAC
LOW TRANSVERSE
LOW VERTICAL
DISPOSITIONHOME WITH MOTHER
TRANSFER
STANDARD FORM 533 (REV. 12-1999) PAGE 9
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. or SSN; Sex; Rank/Grade)
REGISTER NO. WARD NO.
NSN 7540-00-634-4276
YES NO
YES NO
POSTPARTUM VISITSDATE ALLERGIES
LAB STUDIES REQUESTED MEDICATIONS/CONTRACEPTION
MEDICATIONS/CONTRACEPTION DISPENSED
CONTRACEPTIVE METHOD
HGB/HCT LAST PAP SMEAR (Date)
INTERIM HISTORY
INTERVAL CARE RECOMMENDATIONSFOR GENERAL HEALTH PROMOTION
FOR REPRODUCTIVE HEALTH PROMOTION
RETURN VISIT (Date)
REFERRALS
EXAMINED BY
PHYSICAL EXAMBP WEIGHT PAP SMEAR
ITEM COMMENTS
BREASTS
ABDOMEN
EXTERNAL GENITALS
VAGINA
CERVIX
UTERUS
ADNEXA
RECTAL-VAGINAL
ABNORMALNORMAL
FEEDING METHOD
COMMENTS
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
NSN 7540-00-634-4276
STANDARD FORM 533 (REV. 12-1999) PAGE 10