Is this a desired pregnancy?
When was the pt's last normal menstrual period?
Is she sure about her dates?
o Was she using contraception?
Inquire about any current symptoms associated with pregnancy; o Nausea, vomiting, constipation, breast tenderness, or fatigue?
Ask about any complications:
Any abdominal pain, cramping, vaginal bleeding, or discharge?
PMH: Any history of?
PSH: Any abdominal or pelvic surgeries?
Allergies: Any known drug allergies?
Medications: Is the pt taking any prescribed or over-the-counter medications?
MH: Inquire about any inheritable genetic disorders in the expectant mother's family and the expectant father's family:
Sickle cell disease or trait
What is the pt's ethnic background?
Is the pt married?
Does she know who the father is? Does the father know?
Is the pt working?
Any exposure to harmful fumes or chemicals?
Any use of alcohol, drugs, or tobacco? (Quantify)
Any intimate partner violence/domestic violence?
Any history of depression?
Any recent travel to areas endemic for Chagas, dengue, malaria, and zika?
Are there pets at home?
Ob/Gyn history: Obtain a complete history of prior pregnancies.
Total number of pregnancies: Delivered, aborted, or miscarried?
Normal spontaneous vaginal delivery, forceps- or vacuum-assisted delivery, or cesarean section?
Length of labor?
Gestational age, birth weight, and length?
Any anesthesia used?
Ectopic pregnancy or multiple births?
Any history of abnormal Pap test or sexually transmitted infections?
How many sexual partners?
ROS: Review each organ system
Check vital signs
Check for hypertension and fever.
Weight (compare to prepregnancy weight)
Result - Copy and paste this output: