Prenatal Care Charting Your Name Planned Unassisted Homebirth Your Address Your City, State zip Phone

Alt Phone Allergies: Substance Use: Gravida: # mm/yy Para: weeks/ gest

Date: Age: Reproductive History Cycle: Length: LMP: BC: Medications:

DOB:

Amount: EDD: Pregnancy Planned:

Pregnancy History Ab/Misc: Live: labor type meds induction length delivery

birth birth place weight

sex

BF Name

1 2 3 4 5 6 7 8 9 10 Pregnancy Problems: Labor Problems: Postpartum Problems: Physical Exam Pre-preg Wt: B/P:
pro: glu: nitr: ket:

Height: Weight: color/clarity: Urine: History Since LMP:

Headaches Nausea Vomiting Abdominal Pain Urinary Complications Vaginal Discharge Vaginal Bleeding Edema (specify area) Rubella Exposure Other Viral Exposure Radiation Exposure Unusual Weight gain/loss Sleep problems Vision problems Fatigue Constipation Hemorrhoids Alcohol Smoking

Pulse:
bl:

Temp:
other:

yes/no

Comments:

page 1 of 5

Prenatal Chart for Your Name Here

Prenatal Flow Chart

EDD: Factors effecting EDD: Known Date of Conception: Cycle Length: Sonogram: Measurements: FHT: Quickening Dates:

Initial Test
Date Blood Type/RH Hct/Hgb Antibody RPR Rubella titer Hepatitis B HIV Other Results

Other
Date Results

Flutters:

Kicks:

Prenatal Exams
Date Wks Gest Pro Glu Nitr Ket BL clarity/color Wt BP Fundal Height FHT Fetal Mvmnt Edema Pulse Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

page 2 of 5

Prenatal Chart for Your Name Here

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

page 3 of 5

Prenatal Chart for Your Name Here

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments:

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

Date

Wks Gest

Pro

Glu

Nitr

Ket

BL

clarity/color

Wt

BP

Fundal Height

FHT

Fetal Mvmnt

Edema

Pulse

Temp

Comments

page 4 of 5

Prenatal Chart for Your Name Here

Additional Prenatal Notes Date Comments

page 5 of 5

Prenatal Chart for Your Name Here