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

[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="http://www.fpnotebook.com" memo="website"][/conditional]