West End Women'S Healthcare Center Vanderbilt Nurse Midwifery Program Page 2
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2
3Do you have an advanced directive/living will?
O NO
O YES
Do you want information about an advance directive/living will? O NO
O YES
Any spiritual/cultural needs that would affect how we care for you?
O NO
O YES
Any objection to receiving blood products? O NO
O YES
Do you live in a/an?
O House
O Apartment/Condo
Where you live do you have:
O Electricity
O Water
O Cooking Facilities
O Stairs
Form of transportation:
O Own a car
O Family/Friends
O Public
O TennCare
How do you want to feed your baby?
O Breast
O Bottle
O Both
O unsure
If your baby is a boy, do you want him circumcised?
O NO
O YES
O Unsure
When you deliver your baby, what type of pain medicine do you want?
O Epidural
O IV Medication
O Nitrous Oxide O None
What type of birth control do you want to use after your baby is born?
O Oral Contraceptive
O Patch
O Nuva Ring
O Condoms
O Depo Provera
O IUD
O Tubal Ligation
O Unsure
Pregnancy History
Pregnancy
Mo/Yr
Gender
Infants
Type of
Pain
Feeding
Infants
Term>37 wks
Hours
Details or
Number
Of birth
Weight
Delivery
Mgmt
Breast
Name
Preterm
In
Complications
At birth
(Vaginal
Or
< 37 wks
Labor
or
Bottle
Cesarean
1.
2.
3.
4.
GYN History:
At what age was your first menstrual period? ________________________________________________________________________________
Regular periods every 28-30 days?
O NO
O YES
Date of last PAP____________________
Results__________________________
Any abnormal PAPS? __________________________
Have you had any abortions/miscarriages? O NO
O YES
If yes, how many? ______ When? ________________
How was your pregnancy confirmed?
O Home pregnancy test
O Doctor’s office
Health Maintenance
Do you exercise regularly?
O NO
O YES
Are immunizations/shots up to date?
O NO
O YES
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