Pregnancy Health Record
Provided by [YOUR NAME] - [YOUR COMPANY NAME]
A. Personal Information
Field | Details |
|---|
Full Name | Adrienne Daniel |
Date of Birth | 05/14/2058 |
Address | Mobile, AL 36601 |
Contact Number | 222 555 7777 |
Email Address | adrienne@you.mail |
Emergency Contact Name | John Daniel |
Emergency Contact Phone | 222 555 77777 |
B. Medical History
Condition | Yes/No | Additional Details |
|---|
Previous Pregnancies | Yes | 2 previous pregnancies, both normal deliveries |
Chronic Conditions (e.g., Diabetes, Hypertension) | No | N/A |
Allergies | Yes | Penicillin |
Medications Currently Taking | Yes | Prenatal Vitamins, 400mg Folic Acid |
C. Current Pregnancy Information
Field | Details |
|---|
Expected Due Date | 03/15/2086 |
Weeks Gestation (at today’s date) | 22 weeks |
Obstetrician/Gynecologist Name | Dr. Sarah Future |
Contact Information | 222 555 7777 |
Pregnancy Type (e.g., Single, Twins) | Single |
Planned Hospital or Birthing Center | Metro General Birthing Unit |
D. Prenatal Check-Up Record
Date | Weight (lbs/kg) | Blood Pressure (mmHg) | Fetal Heart Rate (BPM) | Notes |
|---|
10/01/2086 | 145 lbs | 120/80 | 150 | Normal check-up; no concerns |
11/01/2086 | 147 lbs | 122/78 | 152 | Ultrasound scheduled for next visit |
E. Lab Tests & Results
Test Name | Date Conducted | Results | Notes |
|---|
Blood Test | 09/15/2086 | Normal | All levels within range |
Urine Test | 09/15/2086 | Normal | No signs of infection |
Ultrasound | 10/15/2086 | Normal | Healthy single fetus |
F. Vaccinations Received During Pregnancy
Vaccine Name | Date Administered | Additional Notes |
|---|
Influenza | 09/20/2086 | No adverse reactions |
Tdap | 10/15/2086 | Recommended booster given |
G. Notes & Observations
Patient is in good health with no complications noted at this stage. Fetal development on track. Continue with prenatal vitamins and regular check-ups.
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