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FIRST VISIT ASSESSMENT
Partner details
Obstetric history (add delivery entries)
Date
Mode
Hospital
GA
Tear
Repair
Maternal complications
Fetal/neonatal complications
PPH
Transfusion
Anti-D
Remove
Medical history (add disorders)
System/organ
Disorder
Status
Disease details
Medications
Remove
Surgical history
Gynaecological surgeries
Procedure
Remove
Non-gynaecological surgeries
Procedure
Remove
Baseline vitals
System examination
Additional information
Anatomy map (abnormal = red)
BOOKING / BASELINE LABS
Routine labs
Blood group
Hb (g/dL)
Ferritin
Rubella status
Varicella status
Syphilis
HSV2 antibodies
Hepatitis B
HIV
Viral load
CD4 count
Hb electrophoresis
Hb electrophoresis abnormalities
Asymptomatic bacteriuria screening
Organism
Treated
Proteinuria
Results
Other results
Cervical screening
Cervical screening status
Previous result
Type of abnormality
Plan of follow-up
Plan of follow-up
Specific labs
Risk of pregestational diabetes
HbA1c
Fructosamine
High risk of infection
Gonorrhea
Chlamydia
Bacterial vaginosis
Tuberculosis
Hepatitis C
Baseline labs completed
Reference range
Indications of testing
Comments
FIRST TRIMESTER ULTRASOUND
Biometry / findings (per fetus)
Overall impression
Plan / recommendations
Genetic screening
Mother
Previous children
First degree relatives
Second degree relatives
Aunts
Uncles
Nephews
Nieces
Mother
Previous children
First degree relatives
Second degree relatives
Aunts
Uncles
Nephews
Nieces
Genetic history counselling note
First trimester screening
First trimester risks
1 :
1 :
1 :
Second trimester screening
Second trimester risks
1 :
1 :
1 :
Cell free fetal DNA (cffDNA) results
Final diagnosis
Carrier screen
Chorionic villus sampling (CVS)
Amniocentesis
Final genetic counselling note
Indication of testing
Aneuploidy screening should be offered to all pregnant women. However, possible outcomes should be discussed including the possibility of high risk results that would warrant invasive testing.
Forms
Open consent forms:
Second trimester ultrasound
General information
Placenta & cord
Amniotic fluid (current fetus)
Biometry (current fetus)
BPDHCACFL
Fetal sex (current fetus)
Adnexa
Right ovary
Left ovary
Uterus
Cranial (current fetus)
Ventricles
Choroid plexus
Cerebellum
Posterior fossa
CSP
Fetal head and neck (current fetus)
Orbits
Nasal bone
Lips and palate
Neck
Fetal heart (current fetus)
Heart position
Four chambers
LVOT
RVOT
Ductal arch
Aortic arch
Fetal chest (current fetus)
Lungs
Diaphragm
Fetal abdomen (current fetus)
Stomach
Umbilical vessels
Left kidney
Right kidney
Bladder
Spine (current fetus)
Spine
Extremities (current fetus)
Upper extremities
Hands
Lower extremities
Feet
Additional information
FINAL DIAGNOSIS
The printed report will include all fetuses, biometry, amniotic fluid, anatomy, and this final diagnosis summary.
