Antenatal Care Information

Please take this summary to your Lead Maternity Carer / Midwife

From:
Patient Name:
Date of Birth:
NHI:
Date of Last Menstrual Period:
Gravida:
Para:
History:
Past obstetric history:

Other Referral Information

Date of most recent appointment:
Next of kin:		Next of Kin Confirmed:
Midwife booked today:	Yes   Name: No

Healthy Pregnancy

Pre-pregnancy BMI:	Height:   Weight:   BMI:
Diet discussed:
Smoking status:
Alcohol consumption:
"Safe Families" screen:
Other drug use:
Other information:

Assessment of Mental Health

PHQ9:
GAD7:
Kessler10:
Notes:

Long Term Conditions

Medical Warnings

Infection Risk Assessment

Swabs taken for chlamydia:	Yes No Not Clinically Indicated
High vaginal swab taken:	Yes No Not Clinically Indicated
Notes:

Screening

Antenatal laboratory screen arranged:
First trimetster screening:	Consider offering and referring for: MSS1 (ideal between 9 – 11 weeks) Ultrasound Scan (ideal between 11 – 13 weeks + 6 days – nuchal lucency) MSS2 (14-16 weeks) Information about First Trimester Screening

Pregnancy information provided

List of LMCs provided:	"Find Your Midwife" site Whanganui DHB list Midwife Availability Whanganui DHB or 0800 MUM TO BE Questions to ask a prospective LMC (prints on A5)
Pregnancy information:	http://www.health.govt.nz/your-health/healthy-living/pregnancy
"Your Pregnancy" booklet given:

Long Term Medications

Other Medications:

Pregnancy Medication

Prescribing Guidelines

Folic acid:
Iodine:

Immunisation

Pertussis: