Thursday, June 25, 2015

Mother's Information Sheet

       In connection with my previous post, here is a sample of the Mother's Information Sheet that I bring with me to the hospital to help speed up or assist in filling out forms once we arrive for baby's delivery.

Mother’s Information Sheet

Name of Mother:  _________________________________
Age / Birthdate: __________________________________                                  
Blood Type & Rh Factor: __________________________
Name of Father: __________________________________
Age / Birthdate:  __________________________________                                         
Blood Type & Rh Factor:  __________________________
Last Menstrual Period or LMP:  ______________________   
Date/Year of First Menstrual Period: ______________________ (yes, they actually 
asked me this question while I was in labor pains!)      
Expected Date of Delivery or EDD:  ___________________
Age of Gestation AOG: ___________________ (No. of weeks upon admittance)
Gravida (G): ___________________ (No. of pregnancies)
Parity (P)    : ___________________ (No. of births > 20 weeks)

Medical Insurance: ________________________________
Attending Obstetrician: _____________________________
Attending Pediatrician:  _____________________________      

Medical History:

Allergies: _________________________________________     
Illness: ___________________________________________
Pregnancy Tests Done: (Examples below)
-         Oral Glucose Tolerance Test
-         CBC – Complete Blood Count
-         Urinalysis
-         Ultrasound
-         Group B Strep
Any Complications during this Pregnancy? (Examples below)
-         Spotting at 6 weeks, given Duphaston 2x a day
-         Premature Contractions and Slight Bleeding due to tiredness 
      at 34 weeks, given Duvadilan 3x a day for 1 week
Do you smoke or drink alcohol?  _______________________
Supplementary Vitamins Taken:  _______________________
Family Medical History: (Examples)
            -     Asthma
            -     Diabetes

As you Reach the Hospital Delivery Room:

How are your contractions? ____________________________
Any pink/bloody discharge? ____________________________
Any rupture of bag? ___________________________________
When was your last food intake or meal? __________________


BABY’S NAME:   ______________________________________ :) 


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