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TSWF-Intake New OB Visit Worksheet with SF600 Version: May-Aug 2017
Patient Name/Contact Number:
Rank:
(Active Duty Only)
DoD ID #:
What is the reason for today’s visit? ___________________________________________________________________
List any concerns or medical symptoms: ____________________________________________________________________________
Past Medical History
Past Medical History
Please note with an [x] any history of the
following:
[ ] Diabetes Mellitus
[ ] Hypertension
[ ] Congenital Heart Disease
[ ] Autoimmune Disease
[ ] Urinary Tract Infection
[ ] Psychiatric Disorders
[ ] Neurologic Disorders
[ ] Epilepsy
[ ] Hepatitis B Virus
[ ] Varicose Veins
[ ] Thrombophlebitis
[ ] Physical Abuse
[ ] Rh Isoimmunization
[ ] Asthma
[ ] Breast Disorders
[ ] Positive PAP
[ ] Uterine Disorders
[ ] Infertility
[ ] Adverse Effect of Anesthetics
[ ] DES Exposure
.....
Infectious Disease History
Infectious Disease History
Please note with an [x] if you’ve been
diagnosed with any of the following:
[ ] Hepatitis
[ ] Herpes
[ ] TB
[ ] Syphilis
[ ] HPV
[ ] HIV
[ ] Chlamydia
[ ] Gonorrhea
[ ] Rubella
.....
Genetic Screening/Teratology
Prior Surgical History
Prior Surgical History
Please note with an [x] any history of the
following:
[ ] Previous ER Visit
[ ] History of Blood Transfusion
[ ] Surgery During Childhood
[ ] Breast Biopsy
[ ] Intestinal Surgery
[ ] Gynecological Surgery
[ ] Epidural Anesthesia
[ ] Episiotomy
[ ] Surgical Treatment for Abortion
[ ] Surgically Induced Abortion
[ ] Laparoscopy w/ Fulgration/Excision of
Gyn Lesion
[ ] Laparoscopy with Adhesiolysis
[ ] Saparoscopy with Aspiration
[ ] Uterine Surgery
[ ] Dilation and Curettage (D&C)
[ ] Abdominal Myomectomy
[ ] Vaginal Myomectomy
[ ] Hysterorrhaphy
[ ] Hysterorrhaphy During Pregnancy
[ ] Hysteroplasty
[ ] Hysterectomy
[ ] Partial Uterine Resection for Intestinal
Pregnancy
[ ] Ovarian Surgery
Infectious Disease Exposure History
Infectious Disease Exposure History
Please note with an [x] if you’ve been
exposed to any of the following:
[ ] Hepatitis
[ ] Herpes
[ ] TB
[ ] Syphilis
[ ] HPV
[ ] HIV
[ ] Chlamydia
[ ] Gonorrhea
[ ] Rubella
.....
Genetic Screening/Teratology
Please note with an [x] if any of the following have
occurred in your family:
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
] Genetic Disease
] Thalassemia Anemia
] Spina Bifida
] Down's Syndrome
] Tay-Sachs
] Sickle Cell Anemia
] Hemophilia A
] Muscular Dystrophy
] Cystic Fibrosis
] Huntington's Disease
] Stillbirth
] Birth Defects
] Autism
] Mental Retardation
] Fragile X
Please rate your pain level on a scale of 0 (no pain) to 10 (severe pain): # ___/10
With regard to pain, please indicate the following: Location:_______________ Duration: _____________ Quality:________________
Factors that correlate with onset:______________________________ Frequency:____________ Average level of pain:____________
Worst level: _______ Least level: ________ What makes it better:_____________________What makes it worse:__________________
LMP/Weight Monitoring/Fundal
Height/FHT
Maternal/Pregnancy History
Personal History/Education and Counseling
[ ] Single [ ] Married [ ] Divorced
[ ] Age at first pregnancy____
[ ] Education- Yrs Completed _____
[ ] Yes [ ] No
Ectopic Pregnancies ________
Total number of pregnancies?___
Term births (>37 wks) _____
First day of Last Menstrual Period:
_____________________________
Premature births (<37 wks) ____
Pre-pregnancy Weight: ______________
[ ] Occupation: ______________
[ ] Religious Affiliation __________
Miscarriages _____
Abortions _______
Living Children _______
[ ] Yes [ ] No
FOR STAFF USE ONLY:
Drug Use
[ ] Yes [ ] No
Congenital Malformations
__________________
[ ] Yes [ ] No
Contraception/Condom Use
Dates
[ ] EDD based on LMP _____
[ ] Yes [ ] No Do you plan to breast
feed?
Type of Delivery:
Vag #_____ C-section #______
[ ] EDD based on U/S _______
Delivery complications:
[ ] Final EDD _______
[ ] Yes [ ] No Desire for postpartum tubal ligation
Wks EGA - Visit Wt - Ttl Wt Gain - FH FHT
[ ] Yes [ ] No Unplanned Pregnancy
Status of baby’s father
[ ] Age _________
[ ] Race/Ethnicity __________
.....
[ ] Yes [ ] No Unwanted Pregnancy
Medical Conditions
Allergies
Immunizations/Disease Prevention (date
completed)
Do you have any of the following? (circle)
High Blood pressure - High Cholesterol
Diabetes - Asthma - Heart Disease
Obesity - Cancer - Had a Heart Attack
Other:
Surgeries or Hospitalizations (dates)
Current Medications
PLEASE INCLUDE DOSAGE. IF YOU HAVE A
LIST WITH YOU HAVE IT READY. (Include
over-the-counter meds, Tylenol, vitamins,
herbal supplements):
Family History
HIGH BLOOD PRESSURE:
HIGH CHOLESTEROL:
DIABETES:
HEART ATTACK: (who, age?)
CANCER: (type, who, and what age when diagnosed?)
OTHER:
Social History
Family/Occupation issues:
Immunizations
[ ]Y [ ]N Reviewed Immunization History
[ ]Y [ ]N Reviewed Immunization Schedule
[ ]Y [ ]N Tdap Vaccine is Up to Date
[ ]Y [ ]N Vaccinations Reviewed and Current as of:
Lipid Screening Blood Sugar Screening HIV Screen Tetanus (Td/Tdap) Influenza Pneumococcal HPV Cervical Cancer Screen Chlamydia Screen Folic Acid .....
What is your preferred language (written or spoken)? _______________________________
What is your preferred method for learning:  Verbal  Written
Visual
 Other: _____________________
Yes No Do you have a learning disability, language barrier, hearing/vision deficit?___________________________
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor
or pharmacy?  Never  Rarely  Sometimes  Often  Always
Yes No Do you have an advance directive? If yes, have you given a copy to your Primary Provider? Yes No
Yes No Do you have any cultural or religious beliefs that may affect your care?
Yes No
Yes No
Are you enrolled in EFMP (Exceptional Family Member Program)?
Enrolled in Relay Health/Secure Messaging? E-mail address if no:________________________________
Yes No Since your last visit with us, have you had any medical care other than in this clinic?
Would you say your general health is  Excellent  Very Good  Good  Fair  Poor
Yes No Is this visit deployment related? If yes, when and where was deployment: _________________________
Yes No Are you currently Active Duty? If yes, have you had a PHA in the last year? Yes No Date of PHA:______
Yes No Special Duty? If yes, check which applies  PRP  SCI  PSP  Flight status  Dive status  Performs Armed Duty
Yes No Have you traveled outside of the US in the last 90 days?
Yes No Do you consume any alcohol?
Yes Never Do you now or have you ever used tobacco products, including smokeless tobacco, e-cigs and vaping? If YES, check the following box
that applies:
 I CURRENTLY USE Tobacco Products- What type? ___________ How much per day? _________Interested in quitting? Yes No
 I QUIT USING Tobacco Products
When did you quit?________________________
Over the last 2 weeks, how often have you been bothered by any of the following problems?
[0]
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
 Not at all
 Not at all
[1]
 Several days
 Several days
[2]
 More than half the days
 More than half the days
[3]
 Nearly every day
 Nearly every day
Yes No Do you feel unsafe or threatened in your personal relationships? (Recommended for females ages 14-46)
Yes No Within the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone?
Yes No Since you’ve been pregnant have you been hit, slapped, kicked or otherwise physically hurt by someone?
Yes No Within the last year has anyone forced you to engage in sexual activities?
FOR STAFF USE ONLY
Maternal Postpartum Depression Screen (Routine screening at 6-8 weeks)
 Edinburgh Postnatal Depression Scale Completed
 Edinburgh Score: _____
----------------------------- (This section NOT for patient use)---------------------------HEALTH
CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
AHLTA was not accessible during this patient visit. Reviewed note & agree with the reverse side ____ (Provider Initial)
VITALS: BP _________ Pulse _______ RR ______ Temp _______ Ht. _______ Wt. ______ O2Sat ______
SUBJECTIVE:
OBJECTIVE:
Patient Accompanied/ Chaperoned by:___________
Vital Signs
[ ] Current Vitals
[ ] Pain Level
General
Appearance
Neck
Breasts
Chest Inspection
Cardiovascular
RRR
Murmur
Abdomen
Gravid
Scar
Skin
Test Results
Hernia
Bowel Sounds
Pap Smear
Abnormal Secretion
Rales
Mass
Rhonchi
Breath/Voice Sounds
Heart Sounds
Abdominal Bruit
Tenderness
Mass Palpated
Liver Enlarged
Vag. Tenderness
Vaginal Cystocele
Cervical Lesion
Adnexae Tender
Vaginal D/C
Vaginal Veside
Vag Rectocele
Cervical D/C
Adnexae Absent
Lesions
Bruising
+/- Vaginal Wet Mount Smear Test
GC/Chlamydia
Lesion
Ext Genitalia
Vaginal Mucosa
Knee Jerk DTR
HPV
Appears Healthy
Thyroid Enlargement
Finding:
Palpation Skin Dimpling
Left
Right
CTA
Neuro
PLAN:
Oriented x3
Lungs
Female Genitalia
ASSESSMENT:
Alert
Samples Taken:
Ankle Jerk DTR
Sensation
Temperature
+/- Vaginal KOH prep test
Spleen Enlarged
Uterus Tender
Uterus Position
Balance