HEALTHCARE MONITORING AND COUNSELING RECORD
FOR PREGNANT STUDENTS
Demographic Data:
Student’s Name:
Married:
■ yes
Home
School:
Date:
■ no
If yes, Husband’s Name:
Address:
Home
Phone:
Maternal Grandmother of Baby:
Work
Phone:
Address:
Work
Phone:
Maternal Grandfather of Baby:
Address:
Student’s Age:
DOB:
LMP:
Current Gravida:
Para:
AB:
Week or Month
of Pregnancy:
EDD:*
First
Appointment:
Clinic or Physician:
Phone:
Routine prenatal healthcare visits are scheduled:
Every 4 weeks up to 32 weeks (end of this period)
Every 2 weeks up to 36 weeks (end of this period)
(Write in pencil)
Then prenatal visits every week until delivery. Record date below for next prenatal appointment and school nurse visit. When the appointment/visit has been kept or changed, record the new date. Student to be seen by school nurse approximately midway between obstetric
visits.
Next Prenatal Appointment:
Next School Nurse Visit:
(Write in pencil)
(Write in pencil)
HISTORY
I. Health problem(s) during past 12 months (list and describe management/treatment):
II. Past History (list with date and age):
Hospitalizations (overnight stay, emergency room visit, outpatient, day surgery):
Illness (contagious diseases, childhood diseases, high fever, etc.):
Injuries (accidents, ingestions, head injury):
Medications:
Allergies:
Last Healthcare Visit Before Pregnancy:
Name of Provider:
Purpose of visit (acute care, routine physical exam):
Last Dental Care Visit:
Purpose:
Provider:
III. Family History:
Biological Father:
Age:
Health:
Maternal Grandparents of Baby:
Paternal Grandparents of Baby:
1. Grandmother -
Age:
Health:
1. Grandmother -
Age:
Health:
2. Grandfather -
Age:
Health:
2. Grandfather -
Age:
Health:
Familial Diseases: (circle) heart disease, stroke, hypertension, diabetes, asthma, allergy, anemia, sickle cell disease or trait, arthritis,
cancer (breast, ovarian), epilepsy, cataracts, glaucoma, kidney disease, tuberculosis, mental problems, mental retardation, learning
problems, congenital anomalies, other.
Explain:
*Expected Date of Delivery
Copyright © 2013 National Association of School Nurses
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IV. Psychosocial History:
Family Support System (friends, relatives, relationships, interactions):
Household Members:
Self-concept (positive/negative feelings about self):
Housing:
Plans for Future:
Self: Education:
Child: Discussion with student date:
Parenting Classes:
Referral for counseling date:
Prenatal Classes:
Follow up / Decision about
High School:
relinquishment or keeping:
Trade School/Alternative School:
Childcare Plans:
College:
Marriage:
V. Past OB History (previous pregnancy if applicable):
Gravida:
Para:
(# of pregnancies)
Delivery Date(s): 1.
2.
3.
AB:
(# of live babies)
Type: (circle)
Maternal Age:
Type: (circle)
Maternal Age:
Type: (circle)
Maternal Age:
Vaginal C-Section
Length of Pregnancy:
Vaginal C-Section
Length of Pregnancy:
Vaginal C-Section
Length of Pregnancy:
If C-Section, why?
If C-Section, why?
If C-Section, why?
Habits: (circle) smoking, drinking, drugs, pica, other
Explain:
High Risks: (circle) infections, bleeding, high blood pressure, anemia, fever, RH factor, trauma, inherited disease(s), medications,
weight gain, chronic disease, hospitalization, other
Explain:
VI. Review of Systems (includes past and present history of each system): (circle and explain)
General: Changes in weight, appetite, activity level, bowel habits, resistance to disease, other. Birth defects (congenital
anomalies)
Skin: Rashes, easy bruising, changes in skin color or texture, eczema, impetigo, growths, or tumors
Head: Headache, trauma, infections
Eyes: Vision changes, trauma, infections, cataracts, glaucoma, other
Ears/Nose/Throat: Infections (specify), trauma, epistaxis, allergies, hearing changes, voice changes, canes, speech
problems
Neck: Trauma, swollen lymph nodes, limitation of movement
Respiratory: Infections, breathing problems, trauma, wheezing, cough, asthma
Cardiovascular: Murmur, fatigue with exertion, cyanosis
Gastrointestinal: Abdominal pain, nausea, jaundice, vomiting, diarrhea, constipation, ulcer
Genitourinary: Infections, enuresis, encopresis, discharge, rashes, menstruation, sexual development
Musculoskeletal: Trauma, limitation of movement, joint pain or swelling, growths of tumor, curvature of the spine, braces, corrective
shoes
Neurological: Birth injury, trauma, seizures (febrile vs. afebrile), staring spells, poor coordination or balance, dizziness, syncope, developmental evaluation
Endocrine: Increased thirst, appetite, urination, diabetes, thyroid problems
Hematologic: Anemia, blood transfusions, blood dyscrasia, sickle cell
Psychosocial: Changes in activity level, behavior, relationships, punishment, rewards
Nutrition: 24-hour recall including snacks
VII. Post Delivery History (current pregnancy):
Labor and Delivery:
Location:
Length of Labor (hrs):
Type of Delivery: (circle)
Condition of Mother (list problems):
Condition of Newborn: Birth Wt.
Ibs.
bleeding, congenital anomalies, feeding, other)
Postnatal: Home from Hospital: Mother in
Complications:
days.
Vaginal
C-section
oz. (breathing, infections, RH factors, jaundice, transfusions,
Baby in
days.
Neonatal (28 days): Complications:
Return to School:
Postpartum Check Up:
Childcare Arrangements:
Pre-Pregnant Weight:
2
Lives with:
Date:
Copyright © 2013 National Association of School Nurses
Pre-Pregnant BP:
/
Date:
MONITORING–COUNSELING RECORD
To be completed at specific intervals between healthcare provider visits.
DATE
WT.
B.P.
VISITS WITH SCHOOL NURSE – COMMENTS: Inquire specifically about headaches,
altered vision, abdominal pain, nausea, vomiting, bleeding, vaginal discharge, dysuria. Ask
about health, nutrition, classes (i.e., prenatal or parenting taken by student).The school nurse
may review a common health problem or concern at each visit and discuss with student.
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Copyright © 2013 National Association of School Nurses
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