PREVIOUS EDITION IS NOT USABLE NSN 7540-00-634-4276

DATE
MEDICAL RECORD PRENATAL AND PREGNANCY
07/01/2013
PATIENT INFORMATION
LAST NAME FIRST NAME MIDDLE INITIAL
Nestor Kathy J
STREET ADDRESS CITY STATE ZIP CODE
333 East 3rd Street Chicago IL 60635
TELEPHONE (Home) TELEPHONE (Work) ID NUMBER DAY OF BIRTH (Month, Day, Year) AGE
AREA CODE NUMBER AREA CODE NUMBER EXT.
312 555-5555 13579 24
RACE EDUCATION (Last grade OCCUPATION
completed)
WHITE HISPANIC WHITE AMERICAN INDIAN/ALASKA NATIVE HOMEMAKER
OUTSIDE WORK
BLACK HISPANIC BLACK ASIAN/PACIFIC ISLANDER STUDENT
MARITAL STATUS TYPE OF WORK
SINGLE MARRIED 16
WIDOWED
DIVORCED SEPARATED EMERGENCY CONTACT TELEPHONE
HUSBAND/FATHER OF BABY AREA CODE NUMBER
NAME TELEPHONE Louise Reddecker 312 666-6666
AREA CODE NUMBER NEWBORN'S PHYSICIAN REFERRED BY
Robert Nestor 312 555-5555 Robertson
FINAL ESTIMATED DELIVERY DATE HOSPITAL OF DELIVERY PRIMARY PROVIDER/GROUP MEDICAID NUMBER/INSURANCE
10/27/2013 Brookside Medical Center BCBS 333-55-8888IL
NUMBER OF PREGNANCIES
TOTAL FULL TERM PREMATURE ABORTIONS INDUCTED ABORTIONS SPONTANEOUS ECTOPICS MULTIPLE BIRTHS LIVING
1 0 0 0 0 0 0 0
PAST PREGNANCIES (LAST SIX)
LENGTH PRETERM
DATE GA BIRTH SEX TYPE PLACE OF LABOR COMMENTS/
OF ANESTHESIA DELIVERY
(MO/YR) WEEKS WEIGHT DELIVERY DELIVERY COMPLICATIONS
LABOR F M YES NO

MENSTRUAL HISTORY
LAST MENSTRUAL PERIOD MENSES FREQUENCY MENARCHE
DEFINITE APPROXIMATE (MONTH KNOWN) MONTHLY PRIOR (Date) Q (Days) ON BCP AT AGE ONSET hCG + (Date)
UNKNOWN NORMAL AMOUNT/DURATION YES CONCEPT
FINAL: 01/13/2012 NO 28 YES NO 11
SYMPTOMS SINCE LAST MENSTRUAL PERIOD
DESCRIBE ALL SYMPTOMS
Nausea, Fatigue, Bloating

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER

(SSN or Other)
LAST FIRST MI

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. REGISTER NO. WARD NO.
or SSN; Sex)

PRENATAL AND PREGNANCY

Medical Record

STANDARD FORM 533 (REV. 12-1999)

Prescribed by GSA/ICMR FMR (41 CFR) 101-11.203
 NSN 7540-00-634-4276
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
Nestor Kathy J 13579
PAST MEDICAL HISTORY
O NEG DETAIL POSITIVE REMARKS O NEG DETAIL POSITIVE REMARKS
ITEM ITEM
+ POS (Include Date and Treatment) + POS (Include Date and Treatment)
PULMONARY
DIABETES
0 (TB, ASTHMA) 0
HYPERTENSION ALLERGIES (DRUGS)
0 0
HEART DISEASE BREAST
0 0
AUTOIMMUNE HISTORY OF
DISORDER 0 ABNORMAL PAP 0
UTERINE ANOMALY/
KIDNEY DISEASE/UTI
0 DES 0
PSYCHIATRIC INFERTILITY
0 0
NEUROLOGIC/ RELEVANT FAMILY
EPILEPSY 0 HISTORY 0
HEPATITIS/LIVER
DISEASE 0
GYN SURGERY
VARICOSITIES/
PHLEBITIS 0 0
THYROID
DYSFUNCTION OPERATIONS/HOS-
0
PITALIZATIONS
TRAUMA/DOMESTIC
(Year and Reason)
VIOLENCE 0 0
HISTORY OF BLOOD ANESTHETIC
TRANSFUSION 0 COMPLICATIONS 0
D (RH) SENSITIZED OTHER (Specify)
0
USE OF TOBACCO USE OF ALCOHOL USE OF STREET DRUGS
NUMBER OF CIGARETTES NO. OF NUMBER OF DRINKS PER DAY NO. OF YEARS AMOUNT PER DAY NO. OF YEARS USE
PER DAY YEARS DRINKING
PRIOR TO NOW PRIOR TO NOW
SMOKED
PRIOR TO PREGNANCY NOW PREGNANCY PREGNANCY

0 0 0 0 0 0 0 0 0
COMMENTS/COUNSELING

GENETICS SCREENING/TERATOLOGY COUNSELING

(Includes Patient, Baby's Father, or anyone in Either Family)
ITEM YES NO ITEM YES NO
PATIENT'S AGE IS GREATER THAN 35 YEARS
MENTAL RETARDATION/AUTISM
THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN, OR ASIAN
BACKGROUND (MCV IS LESS THAN 80) IF YES, WAS PERSON TESTED FOR FRAGILE X
NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA, OR
ANENCEPHALY) OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER
CONGENITAL HEART DEFECT MATERIAL METABOLIC DISORDER *E.G., INSULIN-DEPENDENT
DOWN SYNDROME DIABETES, PKU)
TAY-SACHS (E.G., JEWISH, CAJUN, FRENCH CANADIAN) PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS
SICKLE CELL DISEASE OR TRAIT (AFRICAN) NOT LISTED ABOVE

HEMOPHILIA MEDICATIONS/STREET DRUGS/ALCOHOL SINCE LAST MENSTRUAL

MUSCULAR DYSTROPHY PERIOD
CYSTIC FIBROSIS IF YES, LIST AGENT(S)
HUNTINGTON CHOREA
RECURRENT PREGNANCY LOSS OR A STILLBIRTH ANY OTHER
COMMENTS/COUNSELING

STANDARD FORM 533 (REV. 12-1999) PAGE 2

 NSN 7540-00-634-4276
INFECTION HISTORY
ITEM YES NO ITEM YES NO
HIGH RISK HEPATITIS B/IMMUNIZED RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD
LIVE WITH SOMEONE WITH TB HISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS
EXPOSED TO TB OTHER
PATIENT OR PARTNER HAS HISTORY OF GENITAL HERPES
COMMENTS

DRUG ALLERGY RELIGIOUS/CULTURAL CONSIDERATIONS ANESTHESIA CONSULT PLANNED

None Baptist YES NO

INTERVIEWER'S SIGNATURE

INITIAL PHYSICAL EXAMINATION

EXAM DATE PRE-PREGNANCY WEIGHT PRESENT WEIGHT HEIGHT BP
02/24/2013 135# 140# 5'4" 110/70
CHECK ONE
ITEM ITEM RESULT
NORMAL ABNORMAL
HEENT VULVA NORMAL CONDYLOMA LESIONS
FUNDI VAGINA NORMAL INFLAMMATION DISCHARGE
TEETH CERVIX NORMAL INFLAMMATION LESIONS
THYROID NO. OF WEEKS:
UTERUS SIZE FIBROIDS
BREASTS 6
LUNGS ADNEXA NORMAL MASS
HEART DIAGONAL CM
REACHED NO
ABDOMEN CONJUGATE

EXTREMITIES SPINES AVERAGE PROMINENT BLUNT

SKIN SACRUM CONCAVE STRAIGHT ANTERIOR
LYMPH NODES SUBPUBIC ARCH NORMAL WIDE NARROW
RECTUM GYNECOID PELVIC TYPE YES NO
COMMENTS (List type and explain abnormality)

MEDICATION LIST
PROBLEMS PLANS
TYPE START DATE STOP DATE
PNVs 02/24/2013

ESTIMATED DELIVERY DATE (EDD)

CONFIRMATION
ACTION DATE WEEKS EDD INITIAL EDD
LMP 01/13/2013 10/21/2013
INITIAL EXAM 02/24/2013 6 10/21/2013 INITIALED BY
ULTRASOUND 03/19/2013 9 10/21/2013 MJH
18-20 WEEK UPDATE
ACTION ORIG. DATE WEEKS NEW DATE FINAL EDD

QUICKENING
10/21/2013
FUNDAL HT. AT UMBIL.
INITIALED BY
FHT W/FETOSCOPE
ULTRASOUND MJH
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID REGISTER NO. WARD NO.
No. or SSN; Sex; Date of Birth; Rank/Grade)

STANDARD FORM 533 (REV. 12-1999) PAGE 3

 NSN 7540-00-634-4276
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
Nestor Kathy J 13579
VISITS
PRETERM LABOR
WEEKS GEST.

CERVIX EXAM
PRESENTATION
HEIGHT (CM)

MENT (Date)
(BEST EST.)

MOVEMENT
SIGNS/SYMPTOMS BLOOD URINE

PROVIDER
(DIL./EFF./

APPOINT-
DATE PRES- (GLUCOSE/ COMMENTS
FUNDAL

WEIGHT
EDEMA

(Initials)
FETAL
SURE ALBUMIN)

NEXT
PRESENT ABSENT

STA.)
FHR

02/24/2013 6 + - 0/0/Fl 110/70 140 Neg/Neg 03/11/2013 MJH Fatigue, Nausea

03/19/2013 9 + - 110/72 141 Neg/Neg 04/07/2013 MJH Scan = Dates

04/07/2013 12 + - 112/68 142 Neg/Neg 05/05/2013 MJH No c/o

05/05/2013 16 15.00 + - 108/66 144 Neg/Neg 06/03/2013 MJH No c/o

06/03/2013 20 19.00 + + 110/72 147 Neg/Neg 07/01/2013 MJH +FM x 2 weeks

07/01/2013 24 106/60 151 Neg/Neg MJH No c/o

PROBLEMS COMMENTS

STANDARD FORM 533 (REV. 12-1999) PAGE 4

 NSN 7540-00-634-4276

LABORATORY AND EDUCATION

TYPE DATE RESULT REVIEWED COMMENTS/ADDITIONAL LAB

A B
BLOOD TYPE
03/11/2013 AB O MJH
D (RH) TYPE
03/11/2013 Neg MJH
NORMAL OTHER
PAP TEST
02/24/2013 ABNORMAL MJH
POSITIVE
HIV COUNSELING/TESTING DECLINED
03/11/2013 NEGATIVE MJH
INITIAL LABS

ANTIBODY SCREEN
03/11/2013 Neg MJH
RUBELLA
03/11/2013 1.23 (Rubella IGG Present) MJH
VDRL
03/11/2013 Neg MJH
PERCENTAGE G/DL
HCT/HGB
03/11/2013 35.8 12.7 MJH
URINE CULTURE/SCREEN
03/11/2013 Neg MJH
HB s AG
03/11/2013 None Detected MJH
AA AS SS AC
HGB ELETROPHORESIS
SC AF TA2

PPD
OPTIONAL LABS

CHLAMYDIA
02/24/2013 Neg MJH
GC
02/24/2013 Neg MJH
TAY-SACHS

OTHER

ULTRASOUND
1st TM Scan confirms EDC, +FHB,
(When indicated/elected)

03/19/2013 Singleton Fetus MJH

8-18 WEEK LABS

MSAFP/MULTIPLE Neg for Trisomy 18, Trisomy 21,

MARKERS 03/19/2013 and Open Neural Tube Defects MJH
AMNIO/CVS

46, XX OTHER
KARYOTYPE
46, XY

AMNIOTIC FLUID (AFP) NORMAL ABNORMAL

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. REGISTER NO. WARD NO.
or SSN; Sex; Rank/Grade)

STANDARD FORM 533 (REV. 12-1999) PAGE 5

 NSN 7540-00-634-4276
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

Nestor Kathy J 13579

TYPE DATE RESULT REVIEWED COMMENTS/ADDITIONAL LAB
PERCENTAGE G/DL
HCT/HGB
24-28 WEEK LABS

1 HOUR
DIABETES SCREEN

FBS 1 HOUR
GTT (If screen abnormal)
2 HOUR 3 HOUR

D (RH) ANTIBODY SCREEN

D IMMUNE GLOBULIN (RHG) SIGNATURE

GIVEN (28 WEEKS)
PERCENTAGE G/DL
HCT/HGB (Recommended)

ULTRASOUND
32-36 WEEK LABS

VDRL

GC

CHLAMYDIA

GROUP B STREP (35-37

WEEKS)

PLANS/EDUCATION
TYPE COMMENTS TYPE COMMENTS
COUNSELED NEWBORN CAR SEAT

ANESTHESIA PLANS POSTPARTUM BIRTH CONTROL

TOXOPLASMOSIS ENVIRONMENTAL/WORK
PRECAUTIONS (CATS/RAW HAZARDS
MEAT)

CHILDBIRTH CLASSES TUBAL STERILIZATION

PHYSICAL/SEXUAL ACTIVITY VBAC COUNSELING

LABOR SIGNS CIRCUMCISION

NUTRITION COUNSELING TRAVEL

LIFESTYLE, TOBACCO,
BREAST OR BOTTLE FEEDING
ALCOHOL
RESULTS TUBAL STERILIZATION
DATE CONSENT SIGNED INITIALS

COMMENTS/COUNSELING

STANDARD FORM 533 (REV. 12-1999) PAGE 6

 NSN 7540-00-634-4276

SUPPLEMENTAL VISITS
PRETERM LABOR

WEEKS GEST.

CERVIX EXAM
PRESENTATION
HEIGHT (CM)

MENT (Date)
(BEST EST.)

MOVEMENT
SIGNS/SYMPTOMS BLOOD URINE

PROVIDER
(DIL./EFF./

APPOINT-
DATE PRES- (GLUCOSE/ COMMENTS

FUNDAL

WEIGHT
EDEMA

(Initials)
FETAL
SURE ALBUMIN)

NEXT
PRESENT ABSENT

STA.)
FHR

PROGRESS NOTES

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. REGISTER NO. WARD NO.
or SSN; Sex; Rank/Grade)

STANDARD FORM 533 (REV. 12-1999) PAGE 7

 NSN 7540-00-634-4276
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
Nestor Kathy J 13579
PROGRESS NOTES

STANDARD FORM 533 (REV. 12-1999) PAGE 8

 NSN 7540-00-634-4276

DISCHARGE/POSTPARTUM

DELIVERY INFORMATION
DELIVERY DATE TYPE OF DELIVERY
VAGINAL CESAREAN
DELIVERY AT (Weeks) SVD EPISIOTOMY FOR REPEAT-FAILED VBAC
PRIMARY
VACUUM LACERATIONS LOW TRANSVERSE
FORCEPS VBAC CLASSICAL REPEAT - ELECTIVE LOW VERTICAL
LABOR ANESTHESIA
SPONTANEOUS AUGMENTED NONE EPIDURAL GENERAL
INDUCED NO LABOR LOCAL/PUDENDAL SPINAL OTHER
POSTPARTUM COMPLICATIONS
NONE HEMORRHAGE INFECTION HYPERTENSION OTHER:
DISCHARGE DATE
DISCHARGE INFORMATION
NEONATAL
SEX DISPOSITION COMPLICATIONS/ANOMALIES
FEMALE CIRCUMCISION HOME WITH MOTHER NEONATAL DEATH
MALE YES NO TRANSFER OTHER
BIRTH WEIGHT NAME OF BABY STILLBIRTH
IN HOSPITAL
MATERNAL
HB/HCT LEVEL CONTRACEPTIVE METHOD (If applicable) MEDICATIONS

FEEDING METHOD DIAGNOSTIC STUDIES PENDING

BREAST BOTTLE
SECONDARY DIAGNOSIS/PREEXISTING CONDITIONS FOLLOW-UP APPOINTMENT
ASTHMA OTHER DATE LOCATION
DIABETES
HYPERTENSION
IMMUNIZATIONS GIVEN REMARKS
D (Rho)(D)) IMMUNE GLOBULIN
DIABETES
OTHER:
INTERIM CONTACTS
DATE COMMENT

SIGNATURE OF PROVIDER (AS REQUIRED)

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. REGISTER NO. WARD NO.
or SSN; Sex; Rank/Grade)

STANDARD FORM 533 (REV. 12-1999) PAGE 9

 NSN 7540-00-634-4276
LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER
Nestor Kathy J 13579
POSTPARTUM VISITS
DATE ALLERGIES

LAB STUDIES REQUESTED MEDICATIONS/CONTRACEPTION

HGB/HCT LAST PAP SMEAR (Date) MEDICATIONS/CONTRACEPTION DISPENSED

YES NO
INTERIM HISTORY FEEDING METHOD

CONTRACEPTIVE METHOD

INTERVAL CARE RECOMMENDATIONS

FOR GENERAL HEALTH PROMOTION

FOR REPRODUCTIVE HEALTH PROMOTION

REFERRALS

RETURN VISIT (Date) EXAMINED BY

PHYSICAL EXAM
BP WEIGHT PAP SMEAR
YES NO
ITEM NORMAL ABNORMAL COMMENTS
BREASTS

ABDOMEN

EXTERNAL GENITALS

VAGINA

CERVIX

UTERUS

ADNEXA

RECTAL-VAGINAL
COMMENTS

STANDARD FORM 533 (REV. 12-1999) PAGE 10

 NSN 7540-00-634-4276
COMMENTS (Continue on back if needed)

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID No. (SSN or REGISTER NO. WARD NO.
other); hospital or medical facility)

STANDARD FORM 533 (REV. 12-1999) PAGE 11