OB Pregnancy Intake Form Template

Patient name: {formtext: name=name} | Date:{time: ddd, DD MMMM YYYY} Patient is a gravida {formtext: name=gravida} para {formtext: name=para} who presents to establish OB care.

Patient is {formmenu: default=sure; unsure; name=lmp} of her LMP {if:lmp="sure"}{formdate: MM/DD/YYYY; name=date} EDD: {time: MM/DD/YYYY; at={=date}; pattern=MM/DD/YYYY; shift=+280D}{endif}.

{if: gravida>1}Patient has a previous pregnancy history that is {formmenu: default=not complicated.; complicated;name=complications}{if:complications="complicated"} by {formparagraph: name=complications} {endif}.{endif}

Past medical history and past surgical history is reviewed. {formtoggle: name=significant for\ ; default=no}It is significant for {formparagraph: name=significant history}.{endformtoggle}

{formtoggle: name=transfer ob care; default=no}The patient transferred care from {formtext: name=previous doctor}. They report they have had {formmenu: default=prenatal labs; 1st trimester ultrasound\ ; 2nd trimester ultrasound; referral to MFM; oral glucose tolerance test; name=pregnancy care items; multiple=yes}. {formtoggle: name=records received; default=no}Records have been requested and received.{endformtoggle}{endformtoggle}