NAME:

T BP /
COMPLICATIONS:
SOCIAL HX:
DATE: TIME:
RR HR %
LABS: PLATELETS:
WORK: NONE/
PROVIDER: PAIN: 0 1 2 3 4 5 6 7 ! 10
IV: LT / RT
"OLE#: # / N ADV$DIR/WILL # / N WANT% # / N
& P
REPEAT C/S:
# / N
MEDS: MEDS: PIT ' ()/(*+ AB)SE% # / N "INANCIAL% # / N
T P A L
WT$ NOW PRE
AMP X D)E ' HO)SE/ APT/ MOBILE HOME
LMP: / /
LAST "OOD DRINK MA&: BOL)S ,
STADOL REL$ PRE": NONE/
MAINTAIN ' ,/-
)/S: / /
NKA / ALLER&IES:
NAT)RAL /IV MED / EPID)RAL
EPID)RAL: (L/-
CHILDBIRTH CLASS: # / N
PLACED B#:
WKS &EST: PEDIATICIAN: SMOKE: C OR PK / DA#
C/O:
HOME MEDS: RISKS: GBS PROLONGED ROM FEVER/ CHORIO PIH/ MAG BS
DIABETES PRE/ POSTMATURE MALPRES DYSTOCIA APGAR WT
SMOKE/ DRUGS ANOMALIES GENETIC/ CHRONIC DISEASE STD
OLIGO/ POLY NONREASSURING PROLAPSE BLEED COOMBS
CA"": ETOH: DR)&S:
SVE: / /
ILLNESS/ HX/ "AMIL# HX:
MARITAL: S W D M:
INTACT / R)P.D:
SROM / AROM
BREAST / BOTTLE / BOTH BTL: # / N CONSENT # / N &IRL / BO# NAME:
'
CLEAR/ MEC/ ODOR:
HX S)R&ER# / ANESTHESIA:
NOTES:
PIH:
CONTRACTIONS: &BS: NE& / POS
)RINE PROTEIN: 0 TR 1 2 3 4
"RE/)ENC# /: MIN$ R)BELLA: IMM /NON
BTL: # / N CONSENT # / N
TIME BE&AN: HEP B: NE& / POS
HA: # / N PAIN 0
MILD/ MOD/ STRON& VDRL: NE& / POS
EPI&ASTRIC PAIN: # / N 0
TONE: SO"T/ HIV: NE& / POS
RE"LEXES: 0 1 2 3 4
"HT.S:
BLOOD: A O AB B
1 22
VIS)AL PROB% # / N
BLEED: # / N COLOR/AMT:
CLON)S: # / N
O)TP)T:
NAME:
T BP /
COMPLICATIONS:
SOCIAL HX:
DATE: TIME:
RR HR %
LABS: PLATELETS:
WORK: NONE/
PROVIDER: PAIN: 0 1 2 3 4 5 6 7 ! 10
IV: LT / RT "OLE#: # / N ADV$DIR/WILL # / N WANT% # / N
& P
REPEAT C/S:
# / N
MEDS: MEDS: PIT ' ()/(*+ AB)SE% # / N "INANCIAL% # / N
T P A L
WT$ NOW PRE
AMP X D)E ' HO)SE/ APT/ MOBILE HOME
LMP: / /
LAST "OOD DRINK MA&: BOL)S ,
STADOL REL$ PRE": NONE/
MAINTAIN ' ,/-
)/S: / /
NKA / ALLER&IES:
NAT)RAL /IV MED / EPID)RAL
EPID)RAL: (L/-
CHILDBIRTH CLASS: # / N
PLACED B#:
WKS &EST: PEDIATRICIAN: SMOKE: C OR PK / DA#
C/O:
HOME MEDS: RISKS: GBS PROLONGED ROM FEVER/ CHORIO PIH/ MAG BS
DIABETES PRE/ POSTMATURE MALPRES DYSTOCIA APGAR WT
SMOKE/ DRUGS ANOMALIES GENETIC/ CHRONIC DISEASE STD
OLIGO/ POLY NONREASSURING PROLAPSE BLEED COOMBS
CA"": ETOH: DR)&S:
SVE: / /
ILLNESS/ HX/ "AMIL# HX:
MARITAL: S W D M:
INTACT / R)P.D:
SROM / AROM
BREAST / BOTTLE / BOTH BTL: # / N CONSENT # / N &IRL / BO# NAME:
'
CLEAR/ MEC/ ODOR:
HX S)R&ER# / ANESTHESIA:
NOTES:
PIH:
CONTRACTIONS: &BS: NE& / POS )RINE PROTEIN: 0 TR 1 2 3 4
"RE/)ENC# /: MIN$ R)BELLA: IMM /NON
BTL: # / N CONSENT # / N
TIME BE&AN: HEP B: NE& / POS HA: # / N PAIN 0
MILD/ MOD/ STRON& VDRL: NE& / POS EPI&ASTRIC PAIN: # / N 0
TONE: SO"T/ HIV: NE& / POS RE"LEXES: 0 1 2 3 4
"HT.S:
BLOOD: A O AB B
1 22
VIS)AL PROB% # / N
BLEED: # / N COLOR/AMT:
CLON)S: # / N
O)TP)T: