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  • Maternal History Interview

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    aringkinking
    41 views4 pages
    This document appears to be a template for recording a maternal history interview. It includes fields for the mother's name, baby's gender, age, address, contact details, and obstetric history. It also includes checkboxes to indicate any pre-existing medical conditions the mother may have, such as cough/colds, asthma, UTIs, hepatitis B, and others. Space is provided to note medications, dates, and details. The bottom includes signatures for the interviewing pediatrician and person who conducted the interview.

    Original Description:

    maternal history form

    Original Title

    Maternal History

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    This document appears to be a template for recording a maternal history interview. It includes fields for the mother's name, baby's gender, age, address, contact details, and obstetric history. It also includes checkboxes to indicate any pre-existing medical conditions the mother may have, such as cough/colds, asthma, UTIs, hepatitis B, and others. Space is provided to note medications, dates, and details. The bottom includes signatures for the interviewing pediatrician and person who conducted the interview.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    41 views4 pages

    Maternal History Interview

    Uploaded by

    aringkinking
    This document appears to be a template for recording a maternal history interview. It includes fields for the mother's name, baby's gender, age, address, contact details, and obstetric history. It also includes checkboxes to indicate any pre-existing medical conditions the mother may have, such as cough/colds, asthma, UTIs, hepatitis B, and others. Space is provided to note medications, dates, and details. The bottom includes signatures for the interviewing pediatrician and person who conducted the interview.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 4

    MATERNAL HISTORY INTERVIEW

    Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


    Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
    Age: _______ Age: _______ Age: _______
    Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
    Contact No: ________________ Contact No: ________________ Contact No: ________________
    AOG: AOG: AOG:
    G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
    Ruptured Time: __________ Ruptured Time: __________ Ruptured Time: _________
    Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

    Maternal Hx Maternal Hx Maternal Hx

    ( ) Cough and colds When: _______________ ( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________
    ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____
    ( ) Allergy ( ) Allergy ( ) Allergy
    ( ) HPN ( ) HPN ( ) HPN
    ( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
    ( ) Goiter ( ) Goiter ( ) Goiter
    ( ) DM ( ) DM ( ) DM
    ( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
    ( ) HepB Medications taken: ( ) HepB Medications taken: ______ ( ) HepB Medications taken: ______
    ______
    Others: Others:
    Others:

    OB/PEDIA:____________________ OB/PEDIA:____________________
    OB/PEDIA:____________________ Interviewed by:_______________ Interviewed by:_______________
    Interviewed by:_______________
    MATERNAL HISTORY INTERVIEW

    Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


    Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
    Age: _______ Age: _______ Age: _______
    Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
    Contact No: ________________ Contact No: ________________ Contact No: ________________
    AOG: AOG: AOG:
    G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
    Ruptured Time: __________ Ruptured Time: _________ Ruptured Time: _________
    Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

    Maternal Hx Maternal Hx Maternal Hx

    ( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________ ( ) Cough and colds When: ________________
    ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____ ( ) Asthma Medications taken: _____
    ( ) Allergy ( ) Allergy ( ) Allergy
    ( ) HPN ( ) HPN ( ) HPN
    ( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
    ( ) Goiter ( ) Goiter ( ) Goiter
    ( ) DM ( ) DM ( ) DM
    ( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
    ( ) HepB Medications taken: ( ) HepB Medications taken: ( ) HepB Medications taken:
    ________________ ________________ ________________
    Others: Others: Others:

    OB/PEDIA:____________________ OB/PEDIA:____________________ OB/PEDIA:____________________


    Interviewed by:_______________ Interviewed by:_______________ Interviewed by:_______________
    MATERNAL HISTORY INTERVIEW

    Name of Mother: _________________________________ Name of Mother: _________________________________ Name of Mother: _________________________________


    Gender of baby: __________________________________ Gender of baby: __________________________________ Gender of baby: __________________________________
    Age: _______ Age: _______ Age: _______
    Address: ________________________________________ Address: ________________________________________ Address: ________________________________________
    Contact No: ________________ Contact No: ________________ Contact No: ________________
    AOG: AOG: AOG:
    G___ P___ BOW Intact G___ P___ BOW Intact G___ P___ BOW Intact
    Ruptured Time: __________ Ruptured Time: __________ Ruptured Time: _________
    Leaking Color: _________ Leaking Color: _________ Leaking Color: _________

    Maternal Hx Maternal Hx Maternal Hx

    ( ) Cough and colds When: _______________ ( ) Cough and colds When: _______________ ( ) Cough and colds When: ________________
    ( ) Asthma Medications taken: ( ) Asthma Medications taken: ( ) Asthma Medications taken:
    ( ) Allergy _______________ ( ) Allergy ________________ ( ) Allergy _________________
    ( ) HPN ( ) HPN ( ) HPN
    ( ) Cardiovascular Dse ( ) Cardiovascular Dse ( ) Cardiovascular Dse
    ( ) Goiter ( ) Goiter ( ) Goiter
    ( ) DM ( ) DM ( ) DM
    ( ) UTI When: ________________ ( ) UTI When: ________________ ( ) UTI When: ________________
    ( ) HepB Medications taken: ( ) HepB Medications taken: ( ) HepB Medications taken:
    ________________ ________________ ________________
    Others: Others: Others:

    OB/PEDIA:____________________ OB/PEDIA:____________________ OB/PEDIA:____________________


    Interviewed by:_______________ Interviewed by:_______________ Interviewed by:_______________
    MATERNAL HISTORY INTERVIEW

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