Pregnancy-Related Symptoms

Obstetrics, Subjective/History Elements
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Pregnancy-Related Symptoms
Onset [text] prior to evaluation
Onset while: [text]

Associated Pain (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Frequency: [text] (is [text] regular)
Duration: [text]
Characterized as: [text] (is [text] contraction-like)

Pain modifiers
Relieved with [text]
Worse with [text]

Pregnancy History:
Gravida [text]
Para [text]
Ab: [text]
LMP: [text]
EDC: [text] (determined by [text])
Gestational Age: [text]

Specific Genitourinary Symptoms:
[select value="no|YES"] <-- Leakage of fluid [text]
[select value="no|YES"] <-- Vaginal Bleeding [text]
[select value="no|YES"] <-- Vaginal Discharge [text]
[select value="no|YES"] <-- Dysuria
[select value="no|YES"] <-- Hematuria

Associated Symptoms:
[select value="no|YES"] <-- nausea
[select value="no|YES"] <-- vomiting
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- fever

Pertinent PMH
[select value="no|YES"] <-- Preterm Labor
[select value="no|YES"] <-- Pregnancy Induced Hypertension (PIH)
[select value="no|YES"] <-- Gestational Diabetes
[select value="no|YES"] <-- STD
[select value="no|YES"] <-- Urinary tract infections
[html]<hr>[/html][checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
reference: contributed by Dr. Scott Moses, creator/author of the <a href="http://www.fpnotebook.com" target="_blank">Family Practice Notebook</a>[/html][/conditional]
Pregnancy-Related Symptoms
Onset prior to evaluation
Onset while:

Associated Pain (0=none, 10=severe)
Location:
Radiation:
Severity now (0-10):
Severity at worst (0-10):
Frequency: (is regular)
Duration:
Characterized as: (is contraction-like)

Pain modifiers
Relieved with
Worse with

Pregnancy History:
Gravida
Para
Ab:
LMP:
EDC: (determined by )
Gestational Age:

Specific Genitourinary Symptoms:
<-- Leakage of fluid
<-- Vaginal Bleeding
<-- Vaginal Discharge
<-- Dysuria
<-- Hematuria

Associated Symptoms:
<-- nausea
<-- vomiting
<-- headache
<-- fever

Pertinent PMH
<-- Preterm Labor
<-- Pregnancy Induced Hypertension (PIH)
<-- Gestational Diabetes
<-- STD
<-- Urinary tract infections

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Result - Copy and paste this output:

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